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May,  1885 


ON 


ASIATIC    CHOLEEA^ 


EDITED    AND    PKEPARED    BY 


S  AVEX] 


EDMUXD  CHARLES  WEXDT,  M.D., 

CURATOR  AND  PATHOLOGIST  OF  THE  ST.  FRANCIS  HOSPITAL  ;  CURATOR  AND  PATHOLOGIST  OF  THE  NEW 

YORK  INFANT  asylum;  MEMBER  OF  THE  NEW  YORK  PATHOLOGICAL  SOCIETY,  OF  THE 

NEW  YORK  NEUROLOGICAL  SOCIETY,  OF  THE  MEDICAL  SOCIETY  OF 

THE  COUNTY  OP  NEW  YORK,  ETC.,  ETC., 


IN  ASSOCIATION  WITH 

Drs.  JOHX  C.  peters,  of  Xew  York;  ELY  McCLELLAN,  U.S.A. ; 
JOHX  B.  HAMILTON,  Surgeox-Gexeral  U.  S.  Marixe  Hos- 
pital Service;  axd  GEO.  M.  STERNBERG,  U.S.A. 

T/ie  Pacific  College  of  Osteopathy 

f.o:;  /IfiQcles,  Cal. 


lUustrattb  foitlj  glaps  attb  Cngiabhigs 


NEW  YORK 

WILLIAM    WOOD    AND     COMPANY 

56  &  58  Lafayette  Place 
1885 


\ll 


Copyright 

WILLIAM  WOOD  &  COIVIPANY 

1885 


The  Publishers' 

PmNTING  AND  ElECTROTYPING  Co., 

39  AND  41  Park  Place, 
New  York. 


PEEFAOE. 

When  the  publishers  proposed  to  the  editor  the  preparation,  by 
a  specified  time,  of  a  volume  on  Cholera,  there  was  a  very  natural 
hesitancy  on  his  part  to  accede  to  their  request.  Indeed,  it  was  out 
of  the  question  for  a  single  individual  in  the  given  time  to  accom- 
plish the  task  in  anything  like  a  satisfactory  manner.  How- 
ever, having  received  assurances  of  cooperation  from  various 
sources,  and  especially  after  having  secured  the  valuable  collabora- 
tion of  Dr.  J.  C.  Peters,  than  whom  probabl}-  no  epidemiologist  is 
better  qualified  to  write  on  cholera,  the  editor  overcame  his  misgiv- 
ings and  undertook  to  prepare  the  present  treatise. 

The  object  of  the  work  is  to  furnish  the  physician  with  a  faithful 
account  of  the  actual  state  of  our  knowledge  regarding  a  disease  that, 
even  at  the  present  writing,  is  by  many  expected  soon  to  visit  our 
shores. 

While  the  experience  acquired  in  past  epidemics  has  been  util- 
ized to  its  fullest  extent,  the  contributors  to  this  volume  have  not 
ignored  the  new  light  shed  on  the  disease  by  the  most  recent  re- 
searches. It  is  hoped  that  in  this  way  the  work  may  prove  accept- 
able to  a  larger  class  of  readers  than  if  a  more  one-sided  presenta- 
tion of  the  subject  had  been  undertaken.  Of  course  the  carrying 
out  of  such  a  plan  has  necessarily  led  to  the  embodiment  of  conflict- 
ing views,  that  may  at  times  appear  rather  confusing. 

Yet  it  is  only  in  relation  to  the  etiology  of  the  disease  that  the 
discord  of  opinion  becomes  unpleasantly  noticeable.  Again,  while 
the  editor  has  not  hesitated  to  freely  express  his  own  convictions, 
mere  polemics  and  all  theoretical  disquisitions  have  been,  as  much 
as  possible,  avoided. 


%0 


r^  . 


^y  PREFACE. 

Being  intended  mainly  for  the  American  reader,  it  is  fitting  that 
the  history  of  cholera  as  it  has  affected  our  own  country,  should  re- 
ceive special  attention.  Accordingly  no  apology  is  needed  for  the 
introduction  of  a  very  complete  account  of  the  disease  as  ob- 
served in  the  different  American  epidemics.  And  it  is  hoped  that 
Dr.  Peters'  name  furnishes  a  sufficient  guarantee  of  the  thorough 
manner  in  which  this  part  of  the  work  has  been  accomplished. 

Dr.  McClellan's  history  of  the  epidemic  as  it  has  affected  the 
United  States  Army  constitutes  an  authentic  record  of  a  highly  in- 
structive subject.  Certainly  nothing  could  furnish  a  more  convincing 
proof  of  the  agency  of  human  intercourse  in  the  dissemination  of 
cholera  than  this  part  of  the  volume. 

A  chapter  will  also  be  found  giving  the  history  of  the  disease  as 
observed  in  the  United  States  Navy.  The  manuscript  was  kindly 
supplied  by  the  Bureau  of  Medicine  and  Surgery  of  the  U.  S.  Navy 
Department,  and  the  editor  takes  this  opportunity  of  extending  his 
thanks  to  said  Bureau. 

It  seems  unnecessary  to  indicate  in  detail  the  plan  and  scope  of 
the  book.  The  editor  may,  however,  be  permitted  to  call  special 
attention  to  the  valuable  article  on  the  prevention  of  cholera,  from 
the  pen  of  Dr.  J.  B .  Hamilton,  Surgeon-General  of  the  Marine  Hos- 
pital Service,  and  the  equally  important  contribution  of  Dr.  G.  M. 
Sternberg,  on  the  destruction  of  cholera  germs. 

As  regards  the  editor's  contributions,  it  is  not  pretended  to  lay 
claim  to  any  originality.  His  aim  has  been  the  modest  and  yet 
difficult  one  of  drawing  from  the  recorded  experience  of  the  best 
writers  as  much  of  the  truth  concerning  cholera  as  was  possible. 
But  he  feels  much  more  certain  of  the  importance  of  what  Avas  at- 
tempted than  of  the  value  of  that  w^iich  has  been  accomplished. 
Still,  it  is  hoped  that  by  collecting  from  widely  scattered  sources, 
information  not  easily  accessible  to  the  practitioner,  and  especially 
by  ample  reference  to  the  most  recent  researches  into  the  nature  of 
cholera,  the  work  may  be  found  of  sufficient  merit  to  take  its  place 
by  the  side  of  other  treatises  on  the  same  subject. 

Of  course  the  doctrine  of  Koch  has  received  considerable  atten- 
tion, and  a  special  chapter  has  been  devoted  to  an  accurate  account 


PREFACE.  y 

of  the  methods  of  preparing  pure  cultures  for  purposes  of  diagnosis. 
As  regards  the  etiology  of  cholera,  the  ground  taken  by  the  editor 
is  that,  while  Koch's  doctrine  has  not  been  finally  established  as  a 
scientific  truth,  it  has  very  much  in  its  favor.  At  the  same  time 
space  has  been  given  to  opinions  directly  traversing  the  points 
claimed  by  the  German  investigator  It  will  be  seen,  therefore, 
that  the  editor  has  treated  the  subject  in  an  unbiased  way.  And 
indeed  the  extremely  divergent  opinions  regarding  cholera  enter- 
tained even  at  the  present  day  Avould  scarce!}'  justify  an  attempt  to 
present  a  completely  harmonious  picture  of  the  disease. 

The  editor  has  relied  for  information  upon  those  American, 
•English,  French,  German,  Italian  and  Spanish  writers  who  are 
recognized  in  their  own  countries  as  the  highest  authorities  upon 
the  subject.  For  valuable  assistance  in  summarizing  foreign 
writings  he  would  here  express  his  obligations  to  Dr.  T.  L.  Stol- 
man,  of  this  city.  His  thanks  are  also  due  to  Dr.  J.  C.  Peters  and 
Dr.  A.  Jacobi,  for  placing  at  his  disposal  their  valuable  libraries. 
Finally,  the  indulgence  of  the  reader  is  asked  for  any  typographical 
errors  that,  in  the  somewhat  hasty  proof-reading,  may  have  been 
■overlooked. 

EDMUND    CHARLES   WEXDT. 
Neiv  Yorh,  May,  1885. 


^ARV  Of- 


co:^TE]srTs. 


PAGE 

Introduction '  .       .       .       .    xi 

PART  FIEST. 
A  HISTORY  OF  ASIATIC  CHOLERA. 

SECTION  I. — General  History  of  the  Disease  and  the  Prin- 
cipal Epidemics  up  to  1885.     By  John  C.  Peters,  M.D. 

CHAPTER  I. 

Early  History  of  Asiatic  Cholei'a  in  India  as  known  to  Europeans    ...      8 

CHAPTER  n. 
The  Great  Epidemic  of  1817 6 

CHAPTER  m. 
The  Epidemic  of  1827  in  India,  which  reached  Russia  in  1829,  England  in  1831, 

and  the  United  States  in  1832 10 

CHAPTER  IV. 

The  First  Epidemic  in  the  United  States,  that  of  1833 16 

Cholera  in  New  York  City  in  1833,  17;  Cholera  in  New  Orleans  in  1833,  24. 

CHAPTER  V. 
Cholera  in  India  from  1830  to  1845. — In  Asia,  Europe  and  America  to  1849       .     26 
Cholera  in  the  United  States  in  1848  and  1849,  27;  Cholera  in  St.  Louis, 
1848-1853,  30. 

CHAPTER  VI. 
Cholera  in  India,  Asia,  Europe,  and  the  United  States,  from  1848  to  1854         .     33 

CHAPTER  Vn. 

The  Epidemic  which  reached  the  L^nited  States  in  1866 35 

Distribution  of  the  first  35  Fatal  Cases  of  Cholera  in  New  York  City  in  1866, 
37;  Cholera  in  Brooklyn  in  1866,  39. 

CHAPTER  Vni. 

Tiie  Cholera  which  reached  the  United  States  in  1873 41 

Epidemic  of  Cliolera  in  the  United  States  in  1873 45 


viii  '  CO^^tENTS. 

.    .  ,  CHAPTER  IX. 

'r'  I  ''l  I  '      '  I      '  PAGE 

Cholera  in  Bombay,  especially  in  1883 ,58 

CHAPTER  X. 
Cholera  in  Eg^'pt  in  1883        , 61 

CHAPTER  XI. 
Cholera  in  France,  Italy  and  Spain  in  1883  and  1884 67 

SECTION  11. — A  History  of  Epidemic  Cholera,  as  it  affected 
THE  Army  of  the  Uxited  States.     By  Ely  McClellan,  M.D. 

CHAPTER  Xn. 
General  Remarks  and  the  Epidemic  of  1833  to  1835     ......     71 

CHAPTER  Xm. 
The  Epidemics  of  1848,  1849,  1850  to  1857      ...  ....     79 

CHAPTER  XIV. 
The  Epidemic  of  1866  in  the  United  States  Army 88 

CHAPTER  XV. 
The  Epidemic  of  1867  in  the  United  States  Army 101 

CHAPTER  XVI. 
The  Epidemic  of  1873  in  the  United  States  Army 109 

CHAPTER  XVn. 

Cholera  on  Shipboard 113 

Memoranda  furnished  by  the  Bureau  of  IMedicine  and  Sm-gery,  U.  S.  Navy 
Department. 


PART  SECOND. 

THE  ETIOLOGY  OF  CHOLERA. 
By  Edmund  C.  Wendt,  M.D. 

CHAPTER  XVEH. 

General  Remarks  and  some  Leading  Theories  on  the  Nature  of  Cholera  .        .119 

CHAPTER  XIX. 
Parasitic  Theories 125 

CHAPTER  XX. 
Other  Views  on  the  Nature  of  Cholera 134 

CHAPTER  XXI. 
The  Doctrine  of  Koch 151 

CHAPTER  XXn. 
Other  Recent  Researches  on  Cholera 170 


CONTEXTS.  ix 

CHAPTER  XXin. 

PAGE 

Tlie  Cholera-Bacillus  Controversy — Koch's  Discoveiy  confirmed       .        .        .  176 

CHAPTER  XXIV. 
The  Cholera  Microbe  of  Emmerich:    with  other  Observations  for  and  against 

Koch 190 

CHAPTER   XXV. 
The  Contagiousness  of  Cholera 198 

CHAPTER   XXVI. 

Conditions  which  favor  the  Origin  and  Dissemination  of  Cholera      .        .        .  208 

PART  THIED. 

THE    SYMPTOMATOLOGY,  COURSE,  DURATION,  MORTALITY,  CO:\I- 

PLICATIONS  AND  SEQUELAE  OF  CHOLERA. 

By  Edmund  C.  Wendt,  M.D. 

CHAPTER  XX^TI. 
Choleraic  Diarrhoea  and  Cholerine 219 

CHAPTER  XXVin. 

Pronovmced  Cholera,  including  the  Prodromal  Stage,  the  Period  of  Attack, 

and  the  Stage  of  Reaction 222 

Analysis  of  the  Leading  Symptoms  of  Asiatic  Cholera 228 

CHAPTER  XXIX. 
The  Coui-se,  Duration  and  Mortality  of  Cholera 248 

CHAPTER  XXX. 
The  CompUcations  and  Sequela?  of  Cholera 254 

CHAPTER  XXXL 
The  Cholera  Typhoid •        ...  259 

CHAPTER  XXXH. 

Pregnancy  and  Childbed  as  Influenced  by  Cholera 263 

PAET  FOURTH. 

THE    MORBID    ANATOMY    AND    PATHOLOGICAL    HISTOLOGY    OF 

CHOLERA. 
By  Edmund  C.  Wendt,  M.D. 

CHAPTER  XXXm. 
Morbid  Appearances  after  Deatli  in  Collapse 267 

CHAPTER  XXXIV. 
Morbid  Appearances  after  Death  following  Reaction 280 


^  CONTEXTS. 

PART  FIFTH. 

PAGE 

DIAGNOSIS,     DIFFERENTIAL     DIAGNOSIS     AND     PROGNOSIS     OF 

CHOLERA.— THE  METHODS  OF  BACTERIOSCOPY  AND  THE 

PREPARATION  OF  PURE  CULTURES. 

By  Edmund  C.  Wendt,  M.D. 

CHAPTER  XXXV. 
Diagnosis  and  Differential  Diagnosis 293 

CHAPTER  XXX\a 
Prognosis        , 306 

CHAPTER  XXX^TI. 
On  the  Methods  of  Bacterioscopy  and  the  Preparation  of  Pure  Cultures  .        .311 

PART   SIXTH. 

THE  PREVENTION  OF  CHOLERA. 

SECTION  I. — The  Desteuctiox  of  Cholera  Germs.    By  George 
M.  Sternberg,  M.D, 

CHAPTER  XXXVm. 
The  Destruction  of  Cholera  Germs — External  and  Internal  Disinfection  .         .  325 

SECTIOX  II. — The  Preyentiox  of  the  Spread  of  Cholera.    By 
John  B.  Hamilton,  M.D. 

CHAPTER  XXXIX. 

Responsibility  of  Nations  and  International  Notification 33{> 

CHAPTER  XL. 
Medical  Inspection,  including  the  Theory  and  Practice  of  Quarantine       .         .  3-l.> 

CHAPTER  XLI. 
Municipal  Measures  and  Personal  Prophylaxis 355> 

SECTIOX  HI. — Cholera  Hygiene  as  applied  to  Military  Life:. 
By  Ely  McClellan,  M.D. 

CHAPTER  XLII. 
Cholera  Hygiene  as  Applied  to  Military  Life 361 

PART   SEYEXTH. 

THE  TREATMENT  OF  CHOLERA. 
By  Edmund  C.  Wendt,  M.D. 

CHAPTER  XLin. 
General  Therapy  and  the  Treatment  of  the  Different  Stages  of  an  Attack       .  369 

CHAPTER  XLIV. 
Special  Methods  of  Treatment  and  Protective  Inoculation 383 


TREATISE  ON   ASIATIC  CHOLERA. 


INTKODUCTIOX. 


Under  the  common  designation  of  Cholera  we  may  properly  include 
three  diseases  which,  while  presenting  a  striking  similarity  in  regard  to 
certain  clinical  phenomena,  must  yet  be  held  to  differ  radically  as  to  their 
origin  and  nature.     These  diseases  are — 

I.  Epidemic  or  Asiatic  Cholera; 

II.  Simi^le  or  Sporadic  Cholera,  commonly  called  cholera  morbus 
in  England  and  our  own  country,  and  cholera  Europaea  or  cholera  nos- 
tras in  continental  Europe;  and 

III.  Cholera  Infantum,  or  choleriform  diarrhoea,  which  is  popularly 
known  in  the  United  States  as  summer  complaint. 

The  three  diseases  named  are  all  characterized  by  more  or  less  vomit- 
ing, frequent  watery  discharges  from  the  bowels,  great  prostration  with  a 
tendency  to  collapse,  and  usually  a  quick  termination  either  in  death  or 
perfect  recovery. '  Indeed  the  clinical  symptoms  of  these  maladies  may  be 
so  much  alike  that,  during  an  outbreak  of  epidemic  cholera,  it  may  appear 
impossible  to  decide,  in  a  given  case,  what  particular  one  we  are  dealing 
with.  Xevertheless  such  apparent  likeness  by  no  means  constitutes  an 
actual  identity,  especially  from  the  standpoint  of  etiology.  And  the 
view,  still  entertained  by  some  writers  of  the  present  day,  and  according 
to  which  these  diseases  are  mere  gradations  of  one  and  the  same  malady, 
must  be  discarded  as  utterly  untenable. 

It  is  well  known  that  cholera  morbus  may  appear  in  any  place  and  at 
any  time,  and  that  cholera  infantum  usually  appears  in  larger  towns  during 
the  hot  season.  But  the  history  of  Asiatic  cholera  demonstrates  con- 
clusively its  specific,  infectious,  and  epidemic  character.  Xor  can  the  en- 
demic presence  of  Asiatic  cholera  in  some  parts  of  India  be  construed  into 
a  valid  argument  against  this  view  of  its  essential  nature. 

'  The  more  protracted  cases  of  Asiatic  cholera  often  assume  a  form  not  unlike 
typhoid  fever,  death  taking  place  by  gradual  asthenia,  or  convalescence  being 
tedious  and  long  delayed. 


xii  ASIATIC  CHOLERA. 

The  final  outcome  of  recent  pathological  research,  especially  as  re- 
gards the  parasitic  origin  of  many  of  our  most  formidable  diseases,  may 
result,  as  some  suppose,  in  blurring  the  boundary  lines  that  now  separate 
them.  But  at  the  present  writing,  the  tendency  certainly  is  in  a  directly 
opposite  direction. 

It  would  be  out  of  place  here  to  discuss  what  is  known  as  the  "  germ 
theory  "  of  disease.  Nevertheless  it  may  be  said  that  the  doctrine  which 
assumes  that  each  infectious  disease  has  its  j^articular  and  specific  microbe, 
is  more  in  accordance  with  known  facts  than  any  theory  yet  promulgated. 

It  is  not  intended  in  this  volume  to  describe  the  second  and  third 
varieties  of  cholera,  the  reader  being  referred  to  the  standard  text-books 
for  an  account  of  cholera  morbus  and  cholera  infantum.  Nevertheless 
these  diseases  will  incidentally  receive  some  share  of  attention,  especially 
in  relation  to  diagnosis  and  difiierential  diagnosis. 

Etymology. — The  etymology  of  the  term  cholera  is  somewhat  doubt- 
ful. Most  probably,  however,  it  is  derived  from  the  Greek.  By  some  it 
has  been  traced  back  to  the  Hebrew  words,  ^7n  ^1?  pronounced  choli-ra 
(bad  disease).  But  Laveran '  says  that  competent  Hebrew  scholars  have 
shown  the  real  meaning  of  these  words  to  have  been  erroneously  interpreted, 
merely  on  account  of  the  similarity  of  pronunciation  between  choli-ra 
and  the  Greek  for  cholera. 

XoXspa,  joAf/j/^  (Ionian)  is  certainly  Greek.  Hippocrates  derived  it 
from  X'^^V  (bile)  and  peco  (I  flow),  believing  that  the  evacuations  wej-e 
caused  by  altered  bile.  Galen  held  that  it  was  derived  from  joA«(j£s' 
(viscera),  as  these  organs  were  always  first  attacked  in  the  disease.  Cel- 
sus  only  admits  the  radical  joA,  meaning  bile,  and  this  is  without  doubt 
the  true  derivation  of  the  word.  The  Greeks  were  in  the  habit  of  adding 
to  the  word  cholera  the  further  designation  of  vovffos  (disease),  and  it  is 
doubtless  for  this  reason  that  we  find  the  Latin  translation  often  rendered 
as  cholera  morbus.  This  was  retained  in  English,  although  at  tlie  present 
day  cholera  morbus  is  used  to  denote  sporadic  or  simple  cholera,  while 
Asiatic  is  added  to  the  term  cholera  to  qualify  the  epidemic  or  malignant 
variety. 

Synonyms. — The  disease  under  consideration  has  been  variously 
known  as  Asiatic  or  Indian  cholera,  serous  cholera,  spasmodic  cholera, 
malignant  cholera,  cholera  asphyxia,  epidemic  cholera,  algid  c^iolera,  blue 
cholera  or  cholera  morbus,  cholera  pestifera.  But  in  English  it  is  most 
commonly  called  Asiatic  cholera;  in  French,  cholera  Asiatique;  in  German, 
Asiatische  or  Indische  cholera;  in  Italian,  colera  Asiatico;  and  in  Spanish, 
colera  Asiatico. 

Definition. — Asiatic  cholera  is  a  specific  infectious  disease  Avhich  is 
endemic  only  in  some  parts  of  India.     From  there  it  may  be  conveyed  all 

^  Article  Cholera,  ki  Dictionnaire  Encyclopedique  des  Sciences  Medicales.  Paris, 
1874,  1st  series,  vol.  xvi. 


INTRODUCTION.  xiil 

over  the  earth  in  the  form  of  more  or  less  mahgnaiit  epidemics.  An  at- 
tack is,  as  a  rule,  characterized  by  premonitory  diarrhoea,  occasional 
nausea,  muscular  debility,  faintness,  and  a  sense  of  prtecordial  oppression. 
Xext  there  arise  the  following  symptoms  :  griping  abdominal  pains,  fre- 
quent purging  of  a  serous  alkaline  fluid  resembling  water  in  which  rice 
has  been  washed  or  boiled,  vomiting,  a  feeling  of  internal  heat  and  actual 
external  coldness.  There  also  commonly  occur  suppression  of  urine, 
cold,  clammy  sweat,  shriveling  of  the  skin,  pinching  of  the  features,  deep 
cyanosis,  subnormal  temperature,  cold  breath,  intense  thirst,  a  peculiarly 
husky  voice,  excessive  restlessness,  violent  muscular  cramps,  and  pro- 
found collapse,  followed  by  speedy  death  or  a  reaction  with  or  without 
fever.  The  British  College  of  Physicians  defines  cholera  as  "  an  epidemic 
disease,  characterized  by  vomiting  and  purging,  with  evacuations  like 
rice-water,  accompanied  by  cramps,  and  resulting  in  suppression  of  urine 
and  collapse." 


PART  FIEST. 


A  HISTORY  OF  ASIATIC  CHOLEEA. 


SECTIOIsr    I. 


GENERAL  HISTORY  OF  THE  DISEASE  AND  THE 
PRINCIPAL  EPIDEMICS  UP  TO  1885. 

BY 

JOHN    C.  PETERS,    M.D. 

OF  NEW  YORK. 


Note. — For  maps  illustrating  the  routes  of  eiiidemic  cholera  in  all  parts  of 
the  world,  the  reader  is  referred  to  the  end  of  Section  I.,  Part  First. 


CHAPTER   I. 

EAELY  HISTORY  OF.  ASLITIC  CHOLERA  IN  INDIA  AS  KNOWN 
TO  EUROPEANS  (A.D.    1503  TO  1800). 

Asiatic  choleka  lias  always  been  present  in  Hindostan,  or  the  land 
of  tlie  Hindoos,  as  long  as  that  country  has  been  known  to  Europeans. 
"When  Vasco  de  Gama  rounded  the  southernmost  point  of  Africa,  which 
he  called  the  Cape  of  Good  Hope,  with  all  the  flags  of  his  gallant  little 
ships  flying,  his  officers  and  men  clad  in  their  gayest  clothes  and  brightest 
armor,  and  his  trumpets  sounding,  he  little  thought  he  was  soon  to  meet 
with  a  new  and  dreadful  pestilence  at  the  courts  of  the  great  King  of 
Calicut,  low  down  on  the  southwestern  or  Malabar  coast  of  India. 

He  landed  in  1498,  and  in  1503  Gaspar  Correa,  an  officer  of  Vasco  de 
Gama,  says  20,000  men  of  Calicut  died  of  a  disease  which  struck  them 
suddenlike  in  the  belly,  so  that  some  of  them  died  in  eight  hours. 

In  1545  he  met  with  it  at  Goa,  further  up  the  west  coast,  where  it  was 
called  Morexy,  "  and  the  mortality  was  so  great  that  the  dead  could  hardly 
be  buried;  so  grievous  was  the  throe,  and  so  bad  the  sort  of  disease,"  says 
Correa,  ''that  the  very  worst  kind  of  poison  seemed  to  be  in  operation;  as 
was  proved  by  the  vomiting,  with  great  drought  for  Avater,  as  if  the 
stomach  was  parched  up;  by  the  cramps  that  fixed  in  the  sinews,  with 
pain  so  extreme  that  the  sufferer  seemed  at  the  point  of  death  and  the 
nails  of  the  hands  and  feet  becoming  "black.''  In  1563  Garcia  d'Orta, 
another  Portuguese,  gave  a  vivid  description  of  cholera  again  at  Goa, 
where  it  was  now  called  hachaiza,  or  haiza,  a  name  by  which  it  is  known 
throughout  India  at  the  present  day;  he  says  it  was  always  most  severe  in 
June  and  July.  In  the  meantime  the  Dutch,  French  and  English  had 
a!lso  sailed  round  the  Cape  of  Good  Hope  to  India;  and  Lindshot,  a  Dutch- 
man, about  1589,  while  residing  at  Goa,  wrote  that  Mordexin.  a  disease 
which  comes  on  very  suddenly,  is  common  and  deadly,  as  it  attacks  the 
stomach  and  bowels  with  continual  vomiting  and  jDurging.  Hence  cholera 
was  first  met  with  on  the  west  coast  of  Hindostan,  south  of  and  far  away 
from  Calcutta  and  the  Ganges.  In  1638  it  again  prevailed  in  Goa,  and 
Thevenot  was  himself  attacked  with  it,  at  Surat,  still  on  the  Avest  coast  and 
north  of  Bombay.  The  first  Englishman  who  described  cholera  Avas  Dr. 
Frye,  who  also  saw  it  along  the  coast  of  Surat  as  early  as  1563. 

In  1628  Bontius,  a  Dutchman,  described  cholera  at  Batavia,  far  to 
the  east  of  Bengal,  and  to  Avhich  it  must  have  been  conveyed  by  ships. 

It  was  noticed  at  Indore,  near  Central  India,  in  1621  and  1681;  also 
at  Mewar,  far  north  of  Surat,  in  1621;  again  at  Nagpore  in  the  very  cen- 
ter of  India  in  1666.  At  Bejapoor,  a  little  north  of  Goa,  in  1687;  also 
at  Masulipatan,  north  of  Madras,  on  the  east  or  Coromandel  coast  in  1687; 
and  in  Ceylon  in  1639. 

In   1733   it  Avas  seen  at  Madras;  in  1739,  at  Delhi,  far  up  in  the  north 

3 


4  ASIATIC  CHOLERA. 

of  India  ;  in  1756  at  Arcot,  just  west  of  Madras  ;  in  1768  at  Pondi- 
cherry,  south  of  Madras;  in  1777  at  the  mouth  of  the  Ganges;  in  1780 
at  Tranquebar,  south  of  Madras;  in  1781  at  Juggernaut,  south  of  Cal- 
cutta, and  at  Ganjani,  near  Juggernaut,  It  did  not  reach  Calcutta,  from 
Juggernaut,  till  1782;  nor  Madras  from  Juggernaut  till  1783,  from  whence 
it  Avas  carried  to  Trincomalee  on  the  east  coast  of  Ceylon  also  in  1783. 

lu  1783,  too,  it  was  at  Hurdwar  far  up  north  at  the  foot  of  the  Hima- 
laya mountains  at  one  of  the  great  twelve-year  festivals.  In  1790  it  was 
again  at  Juggernaut,  near  Chilka  Lake,  to  which  the  idols  of  Juggernaut 
had  been  taken  for  safety  against  the  Mohammedans  who  were  besieging 
Juggernaut.  It  may  be  noticed  here  that  the  twelve-year  Juggernaut 
festivals  precede  those  of  Hurdwar  and  some  other  places  by  two  years. 
The  Juggernaut  festivals  fell  in  the  year  1781;  those  of  Hurdwar  in  1783. 
The  frequent  outbreaks  about  Madras  were  connected  with  the  festivals 
at  Arcot,  Vellore,  Conjiveram,  etc.,  near  by.  as  we  will  see  hereafter. 

One  of  the  earliest  English  accounts  is  by  Dr.  Paisley  of  Madras,  in  1774. 
He  writes  to  Dr.  Curtis:  "  I  am  glad  you  caused  the  army  to  change  its 
(iamping  ground,  for  there  is  no  doubt  the  soiled  ground  contributed  to 
the  frequency  and  violence  of  the  attacks  of  this  dangerous  disease,  true 
cholera,  which  is  the  same  Ave  had  at  Trincomalee.  It  is  often  epidemic 
among  the  natives:  in  our  first  campaign  it  was  terribly  fatal  among  them, 
and  fifty  European  soldiers  also  died.  I  have  met  with  many  cases  since." 
The  only  claim  of  Calcutta  and  Bengal  to  priority  in  cholera  is  that  given 
by  Macuamara  avIio  says,  "there  was  a  temple  to  Oola  Beebee,  or  the  Goddess 
of  cholera,  near  Calcutta,  in  1720,  which  is  visited  by  pilgrims  to  this  day 
every  Tuesday  and  Saturday,  especially  from  April  to  June,  in  cholera 
times.  The  pilgrims  fast  in  the  morning,  dine  at  two  o'clock,  Avhen 
they  eat  crushed  rice  and  a  preparation  of  milk,  and  pay  the  priests."  _ 

The  most  suggestive  early  outbreak,  Avhich  should  have  attracted  more 
attention  long  ago  Avas  among  Colonel  Pearse's  5,000  troops  marching 
in  March,  1781.  at  Ganjam,  near  Juggernaut.  He  reports  that  in  addi- 
tion to  those  Avho  died,  there  were  500  in  hospital,  on  March  22,  and 
says:  "  Death  raged  in  the  camp,  Avith  a  horror  not  to  be  described,  and 
all  expected  to  be  destroyed  by  the  pestilence.  I  first  attributed  it  to 
poison,  but  soon  found  there  had  been  a  pestilential  disease  raging  among 
the  natives  in  the  parts  througli  Avhich  our  marches  lay,  and  that  part  of 
our  camp  was  drinking  in  death  and  destruction.  In  a  fcAv  days,  1143 
men  Avere  in  hospital;  but  on  March  26th  there  Avere  only  908,  and  on  the 
first  of  April  the  army  Avas  able  to  march  again,  leaving  300  con\-alescents 
behind."  The  supreme  government  report  adds:  "  the  pestilence  found 
its  Avay  to  Calcutta,  chiefly  afi'ecting  the  native  inhabitants  Avitli  great 
mortality,  and  is  also  pursuing  its  course  to  the  north Avard."  This  is 
the  first  authentic  account  of  a  Juggernaut  cholera  carried  to  Calcutta. 
It  has  since  been  repeated  so  frequently  that  the  Avords:  "  cholera  raging  at 
Juggernaut,  and  beginning  in  Calcutta,"  are  almost  stereotyped.  This  epi- 
demic was  carried  far  up  to  the  north,  reinforced  by  pilgrimages  to  Gaya, 
just  beloAV  Benares,  to  Benares,  and  Allahabad  at  the  junction  of  the 
Ganges  and  Jumna  rivers;  and  so  on  to  HurdAvar,  Avhich  it  reached  in 
1783,  as  before  said,  at  the  great  tAvelfth-year  pilgrimage,  Avhich  takes  place 
there  Iavo  years  after  the  great  tAvelfth-year  pilgrimages  to  Juggernaut: 
for  among  the  Hindoo  priests  there  is  the  same  riA^alry  as  among  the  op- 
posing sects  of  Persians,  Arabians,  Mohammedans,  and  among  Catholics 
and    Protestants,   and    Mohammedans   and  Israelites.     At   Hurdwar  in 


CHOLERA   FROM   1503  TO   1800.  5 

April,  1783,  in  less  than  eight  days,  20,000  pilgrims  were  cut  ofiE  by  cholera. 
How  much  further  to  the  north  it  went  no  one  knows. 

But  from  Ganjam  and  Juggernaut  it  also  went  south  with  Col.  Pearse's 
troops,  and  by  infected  natives  to  Madras.  Dr.  Girdlestone  remarks: 
"■  Spasms  of  the  bowels  were  the  first  disease  Avhicli  appeared  among  the 
European  troops  at  Madras  in  October,  1783.  More  than  fifty  of  these 
men  were  killed  by  them  in  the  first  three  days  after  they  arrived;  and 
in  less  than  three  months  upward  of  1,000  had  suffered  from  these  com- 
])laints.'''  He  says  there  was  coldness  of  the  skin,  especially  of  the  hands; 
feebleness  of  the  pulse,  spasmodic  contractions  of  the  legs,  coldness  of  the 
hands  and  feet,  which  were  sodden  with  cold  sweats,  lividness  of  the  nails, 
cold  breath,  insatiable  thirst,  and  incessant  vomitings,  terminating  in 
speedy  death  if  not  checked.  By  May,  1782,  cholera  had  been  carried 
to  the  English  fleet  at  Trincomalee,  on  the  east  coast  of  Ceylon,  and  the 
Frenchman  Sonnerat  says  it  prevailed  along  the  Coromandel,  or  east 
coast  of  India,  especially  in  the  neighborhood  of  Madras,  from  1772  to 
1782.' 

In  1796  Fra  Paolino  Bartholomeo  published  at  Eome  a  curious  account 
of  cholera  on  the  west  or  Malabar  coast, and  says  it  was  there  called  Nivcouhen 
in  the  Malabar  language,  Monlexin  in  Sanscrit,  and  not  Mart  dc  Chien  or 
"'  dogs  death,"  as  it  is  called  by  Sonnerat.  He  says,  "  It  is  most  frequent 
in  October,  November  and  December,  Avhen  the  cold  winds  come  from 
the  ocean  loaded  with  salt  and  nitre:  while  on  the  east  or  Coromandel 
coast  it  is  most  common  in  April  and  May,  when  it  often  carries  off  thirty 
or  forty  persons  in  one  village  in  one  night.  In  1782  it  prevailed  with 
terrible  ferocity  and  destroyed  an  enormous  number  of  people.''  None 
of  these  writers  seemed  to  recognize  the  horrible  filthiness  of  the  Hindoo 
villages,  but  only  talk  about  rains,  winds,  malaria,  soil,  heat  and  what 
not. 

The  Rev.  Father  Sangermano  says  it  prevailed  in  Burmah  far  east  of 
the  Bay  of  Bengal  in  178 

It  will  be  seen  from  the  accompanying  map  that  cholera  did  not 
originate  in  Bengal  or  Jessore  in  1817,  as  is  usually  supposed. 

It  was  noticed  on  the  west  coast  of  India  long  before  it  was  seen  on 
the  east  coast.  It  was  felt  at  Calicut,  Goa,  Bombay  and  Surat,  on  the 
Avest  coast,  nearly  tAvo  hundred  3'ears  before  it  was  recorded  at  Calcutta, 
Jessore,  or  Madras,  on  the  east  coast. 

The  same  holds  true  to-day:  Calcutta  and  Bengal  unfortunately  have 
not  a  monopoly  of  cholera,  but  all  India  is  possessed  with  it.  The  Bengal 
official  reports  and  maps  indicate  that  there  was  no  cholera  in  Bombay 
except  occasionally,  and  then  only  when  derived  from  Bengal  previous  to 
1855.     (See  table  of  mortality  for  Bombay.) 

'  The  whole  of  this  great  epidemic  of  1781  to  1783  was  a  great  twelve-year 
festival  outbi'eak,  such  as  we  will  see  was  supplemented  in  1817,  or  three  times 
twelve  years  afterward;  and  extended  from  Juggernaut  on  the  middle  east  coast 
to  Calcutta  and  Hurdwar  in  the  north;  down  to  Madras  and  Ceylon  in  the  south- 
east, and  also  over  to  the  west  or  Bombay  coast.  The  details  of  this  epidemic 
are  almost  the  counterparts  of  those  which  will  now  be  given  of  the  great  out- 
break in  1817. 


ASIATIC  CHOLERA 


CHAPTER  11. 

THE  GREAT  EPIDEMIC  OF  1817. 

In"  1808  there  were  only  five  cases  among  the  European  troops;  in  1811, 
1812,  and  1813,  no  less  than  twenty-nine  cases  at  Chunar;  and  in  1814  there 
were  deaths  at  Cawnpore,  Nagpore,  Benares,  and  finally  at  Dinapore  near 
Calcutta — in  all  forty-six  cases.  In  1815  and  1816  there  were  no  cases 
reported  among  the  English  soldiers.  In  short,  from  1503  to  1817  there 
Avere  no  less  than  ten  epidemic  outbursts  in  India,  so  thai;  it  was  no  new 
thing  for  cholera  to  spread  wide  over  the  country;  but  there  were  so  few 
Europeans  dwelling  there  that  they  were  not  made  public.  Besides,  no 
medical  board  was  established  till  1786,  and  its  reports  were  not  published 
till  1818. 

The  great  epidemic  of  1817  is  usually  supposed  to  have  commenced  in 
August  at  Jessore  in  the  Sunderbunds,  northeast  of  Calcutta  and  near  the 
great  city  of  Dacca,  at  the  confluence  of  the  Ganges  and  large  Brahma- 
pootra rivers.  But  it  was  only  more  severe  at  Jessore,  and  they  were  more 
frightened  and  made  a  greater  outcry.  Cholera  was  at  Patna  and  My- 
mensing,  far  above  Calcutta,  in  July;  and  was  so  severe  in  Calcutta  itself 
in  July  that  the  government  board  returned  word  to  the  Jessore  authorities 
that  their  pestilence  was  only  the  usual  epidemic  of  the  season,  which 
had  already  been  more  fatal  in  the  native  or  "black"  town  of  Calcutta 
than  at  any  former  period  in  the  recollection  of  the  oldest  inhabitants. 
And  it  was  probable  that  no  considerable  town  in  the  low  and  humid  cli- 
mate of  Bengal  was  entirely  exempt  from  it  (Macnamara). 

Still  Dr.  Barnes  of  Jessore  threw  much  light  upon  the  causes  of  the 
outbreak.     He  says: 

"They  are  not  to  be  mistaken,  although  they  ai'e  too  extensive  to  be  brought 
under  human  control.  Putrid  exhalations  from  the  constant  and  rapid  decompo- 
sition of  animal  and  vegetable  matter  and  the  use  of  unwholesome  water,  are  the 
sole  causes.  The  atmosphere  of  Bengal  is  close,  heav\',  and  moist;  and  the  ther- 
mometer never  lower  than  To'' F.  from  March  to  November."  "In  such  a  cli- 
mate," continues  Barnes,  "any  person  acquainted  with  the  materials  that  accu- 
mulate in  Hindoo  towns  and  villages,  and  with  the  crowded,  filthy  and  unventi- 
lated  state  of  the  houses  and  streets,  must  be  satisfied  that  these,  of  all  others, 
are  the  conditions  most  favorable  for  the  infection  and  at  times  even  contagion. 
The  huts  of  the  poorer  natives  were  surrounded  with  every  kind  of  nastiness  as 
well  as  stagnant  water,  and  the  exhalations  from  them  were  at  times  almost 
insupportable." 

Dr.  Barnes  did  not  place  much  stress  upon  mere  swamp  malaria,  but 
much  upon  Avhat  is  now  called  "  civic  malaria."  While  he  had  so  much 
filth  directly  under  his  eyes  and  nose,  he  troubled  himself  little  about  east 
winds,  subsoil  water,  the  barometer,  or  the  so-called  epidemic  constitution 


THE  GREAT  EPIDKMTC  OF   1817.  7 

of  the  air.     He  found  enough  on  the  surface  of  the  earth  without  digging 
deeper  or  soaring  higher. 

The  pestilence  advanced  so  rapidly  up  the  Ganges  and  over  Bengal  that 
by  October,  1817,  it  had  covered  195,935  square  miles,  and  within  this  vast 
area  the  inhabitants  of  scarcely  a  single  village  or  town  had  escaped  its 
deadly  influence.  It  had  passed  Benares,  and  reached  the  great  distribut- 
ing city  of  Mirzapore,  near  Allahabad,  to  the  south  of  which  the  Mar- 
quis of  Hastings'  army  of  10,000  men  and  70,000  camp  followers  was 
moving  still  further  south.  Cholera  commenced  among  the  native  camp 
followers  with  97  deaths  on  Xovember  13th,  and  the  Marquis  then  said: 
"There  is  an  opinion  that  the  water  of  the  tanks,  the  only  water  we  have, 
is  unAvholesome;  therefore  I  will  move  to  the  river  Pohooj,  though  I 
have  1,000  sick."  Xov.  15  he  writes:  "  We  crossed  the  river  this  morn- 
ing. The  march  was  terrible  from  the  number  of  poor  creatures  falling 
sick  from  sudden  attacks;  and  the  quantities  of  those  who  have  died  in 
the  wagons,  whose  bodies  had  to  be  thrown  out  without  burial  to  make 
room  for  the  new-comers;  500  died  since  sunset  yesterday,  ten  of  my 
body  servants  among  them.  The  ground  is  sandy  and  porous,  and  there 
is  an  abatement  of  the  contagion.  Still  numbers  of  dead  and  dying  meet 
the  eye  in  every  direction.  Xov.  17:  The  surgeons  wish  me  to  remain 
another  day,  but  the  stream  is  too  small  for  our  wants,  and  is  muddy.  I 
think  of  moving  to  the  river  Betwah,  which  is  large  and  limpid.  Xov.  19: 
we  marched  fifteen  miles  to  this  broad,  clear  stream  which  has  lofty  banks,, 
and  there  is  a  favorable  change.  Xov.  21  there  is  an  unquestionable  im- 
provement; no  one  can  comprehend  .my  sensations  on  hearing  laughter  in 
the  camp  this  morning  for  the  first  time."  The  disease  disappeared  like 
magic;  but  not  before  over  12,000  had  died. 

The  Marquis's  account  is  one  of  the  most  graphic  and  touching  that  has 
ever  been  given.  He  says,  after  creeping  about,  as  usual,  for  some  time 
among  the  lower  classes  of  camp  followers,  it  suddenly  burst  forth  with 
irresistible  violence  in  every  direction.  The  natives  deserted  in  great  num- 
bers, and  the  highways  and  fields  for  many  miles  around  were  strewn  with 
their  dead  bodies.  The  line  of  march  of  the  white  troops  soon  presented 
a  most  deplorable  spectacle.  The  greater  part  of  the  sick  were  left  be- 
hind, although  all  the  baggage  and  ammunition  were  thrown  away  and  the 
carts  taken  to  swell  the  number  of  ambulances.  Many  who  left  the 
wagons,  pressed  by  the  sudden  calls  of  the  disease,  were  unable  to  rise  again, 
and  were  necessarily  abandoned.  Hundreds  dropped  down  at  every  day's 
advance,  and  more  were  left  behind  at  every  night's  halt.  The  places  of 
encampment  and  lines  of  route  presented  the  appearance  of  a  deadly 
battle-field  and  the  track  of  an  army  retreating  under  every  circumstance 
of  defeat  and  discomfiture.  He  gave  instructions,  if  he  should  die 
himself,  that  his  body  should  be  buried  privately  in  his  own  tent  to  prevent 
a  panic  among  his  troops.  Some  of  his  own  table  servants  had  dropped 
down  while  waiting  upon  him  and  his  staff.  We  are  here  reminded  of  the 
sudden  outbreak  in  Col.  Pearse's  army,  near  Juggernaut,  in  1781,  and  in 
Col.  Crockett's  force  near  the  same  place  in  1790. 

A  considerable  force  of  Madras  troops  was  marching  up  from  the  south  to 
join  the  Marquis  of  Hastings.  It  had  suffered  many  privations  and  much 
fatigue  and  excessive  heat,  but  had  had  no  cholera  until  it  got  to  Nagpore 
in  central  India,  where  we  have  seen  cholera  had  been  in  1666.  Col.  Adams 
had  scarcely  heard  that  the  pestilence  was  in  his  vicinity  before  his  troops, 
which  were  in  high  health,  w^ere  attacked,  especially  while  loitering  for 


S  ,,,     :  A^I^^^T^CiOHOLERA. 

water  at  the  neignboring  riTtdfets;*  seventy  were  seized  the  first  day  and 
more  than  tweuty  died  the  first  night. 

From  Nagpore  tlie  great  high-road  southwest  to  Bombay,  by  way  of 
Janhiah.  Aurungabad  and  Poonah,  was  soon  involved  by  the  troops,  in 
spite  of  a  strong  southwest  monsoon  which  was  blowing  directly  from  the 
Arabian  sea. 

In  the  meantime  troops  were  also  being  sent  up  from  Bombay  toward 
central  India,  and  pilgrims  going  to  the  great  festival  at  Punderpoor,  be- 
low Bombay,  crossed  their  line  of  march.  A  great  outbreak  took  place 
and  3^)00  pilgrims  died  in  the  course  of  a  few  days,  and  the  rest  on  their 
dispersion  carried  the  pestilence  in  every  direction.  Punderpoor  has 
often  since  played  a  great  part  in  the  Bombay  epidemics. 

The  progress  of  cholera  from  Nagpore,  in  central  India,  down  to 
Bombay  had  been  carefully  watched  and  traced  from  city  to  city  and 
village  to  village,  creeping  or  even  Jumping  along  by  the  arrival  of  persons 
from  places  known  to  be  infected.  Some  towns  escaped  for  months  Avhere 
this  sort  of  communication  was  not  frequent,  or  the  water  supply  was 
good.  It  was  pronounced  capable  of  transportation  from  place  to  place. 
It  was  regarded  as  infectious,  but  only  under  some  peculiarities  of  the  con- 
stitution of  the  patient,  or  of  the  local  conditions  of  the  jDlace,  or  of  its 
water  supply.  Surgeon  Coats  thought  if  it  was  occasioned  by  some 
general  distemperature  of  the  air  it  Avould  have  spread  over  the  country 
with  more  regularity,  and  have  attacked  all  parts  of  a  town  more  equally. 
But  it  seemed  only  to  travel  over  roads,  and  when  the  population  was 
scanty  and  the  intercourse  slight  its  progress  was  slow. 

The  Presidency  of  Bengal  contains  much  more  than  one-half  of  the 
whole  population  of  India.  The  valley  of  the  Ganges  is  perhaps  the 
most  populous  in  the  world  and  has  the  greatest  number  of  large  towns, 
cities  and  villages.  The  pilgrimages  to  every  part  of  the  Ganges  are 
numerous  and  even  almost  incessant.  Hence  the  progress  of  cholera  in 
Bengal  seemed  confused  and  indeterminate.  But  as  soon  as  it  reached 
central  India,  where  the  population  is  sparser  and  the  roads  fewer,  and 
every  objective  point  was  watched  by  intelligent  and  responsible  army  sur- 
geons, the  more  or  less  regular  and  progressive  advance  of  the  pestilence 
was  at  once  noted,  and  that  it  marched  even  against  the  most  powerful 
monsoons  and  winds. 

Cholera  prevailed  in  the  Bombay  Presidency  in  1818,  1819,  1830 
and  1821,  and  over  150,000  town  and  country  people  died  of  it.  During 
these  years  it  also  traversed  almost  the  whole  of  India.  From  Allahabad, 
a  somewhat  central  city  toward  the  north,  it  was  carried  up  to  Lucknow, 
Oude,  Delhi,  Hurdwar,  Lodiana,  Lahore,  and  even  to  Peshawur  in  the  ex- 
treme northwest. 

From  Nagpore,  in  the  very  center  of  India,  it  went  directly  south  to 
Hyderabad,  Bejapoor,  Gooty,  Bangalore,  Seringapatam,  Mysore,  Bellary, 
Madura,  and  down  nearly  to  Cape  Cormorin,  the  southernmost  point  of 
India. 

From  Juggernaut  it  traveled  down  the  east  coast  to  Madras  against 
the  heaviest  Avinds  and  the  southeast  monsoon,  and  was  carried  in  ships 
over  to  Trincomalee  in  Ceylon,  and  from  thence  in  ships  to  Mauritius 
and  Madagascar. 

From  Calcutta  it  was  sent  northeast  by  land  toward  Burmah  and  China, 
and  southeast  to  Batavia,  Java,  and  the  Philippine  Islands  and  to  China  in 
ships.     No  winds  could  have  carried  it  throughout  the  Eastern  Archipel- 


THE  GRKIT   EPIDEMIC  OF  1817.  9 

ago  without  its  attacking  many  more  islands  than  it  did.  It  only  broke 
out  in  those  in  which  it  was  landed  from  ships. 

From  Bombay  on  the  Avest  coast  it  was  sent  in  ships  to  Muscat  and 
other  places  on  the  Persian  Gulf.  In  1821,  800  English  troops  under 
Col.  Thompson  were  sent  to  Muscat  to  punish  pirates.  They  carried 
the  disease  with  them  and  landed  it  on  the  east  coast  of  Arabia.  It  also 
prevailed  in  Surat  and  Kurrachee,  and  from  these  three  cities  120  British 
and  130  country  vessels  were  going  every  year  to  the  Persian  Gulf.  The 
harbor  of  ^Muscat  is  so  land-locked  that  few  winds  can  blow  into  it;  and 
it  is  distinctly  stated  that  it  Avas  brought  there  in  ships. 

It  was  also  carried  to  Bushire,  far  up  the  Persian  Gulf,  and  to  Basso- 
rah  at  the  very  head  of  it,  by  English  ships.  At  Bassorah  18,000  are  said 
to  have  died  in  the  course  of  a  few  weeks,  doubtless  from  water  contami- 
nation, and  from  there  it  was  transported  up  the  river  Euphrates  to  Bag- 
dad, which  became  affected  as  well  as  the  surrounding  country.  A  Per-, 
sian  army  lay  before  Bagdad,  and  lost  over  2,000  men  in  a  short  time,  and 
then  retreated  north,  carrying  the  disease  with  it  as  far  as  Tabreez,  just 
between  the  Black  and  Caspian  seas. 

Kerbela  and  Meschids  Hossein  and  Ali,  those  great  places  of  pilgrim- 
age, became  involved,  and  pilgrims  and  travelers  carried  it  to  Aleppo, 
Antioch  and  Damascus,  almost  to  the  east  coast  of  the  Mediteranean  sea, 
where  it  died  out  in  1823. 

From  Tabreez  it  was  carried  up  between  the  Black  and  Caspian  seas 
to  Tiflis  in  the  Caucasus,  whence  it  went  through  the  only  mountain  pass, 
that  of  Dariel  toward  Russia,  and  finally  reached  Astrakhan  both  by  land 
and  by  shijos  from  the  foot  of  the  Caspian  sea.  It  arrived  at  Astrakhan  in 
September,  1823,  where  it  died  out  in  the  winter  and  did  not  reappear 
until  six  years  after,  when  it  was  reimported. 

Many  assumed  that  cholera  was  blown  over  the  Caucasus  mountains, 
which  are  6,000  feet  high.  In  1822  the  pass  of  Dariel  was  a  mere  moun- 
tain road;  next  it  became  a  Russian  military  road,  and  now  a  railroad 
leading  straight  to  Moscow  runs  through  it.  Cholera  has  been  carried 
through  it  again  and  again  by  soldiers  and  travelers. 


l(\  ASIATIC  CHOLERA. 


CHAPTER  III. 

THE    EPIDEMIC    OF    1827    IN    INDIA,     WHICH    REACllED    RUSSIA    IN 
1829,   ENGLAND  IN  1831,   AND  THE  UNITED   STATES  IN  1832. 

Ix  1820  there  was  little  or  no  cholera  in  India.  In  June  1821  it  pre- 
vailed to  such  an  extent  near  Juggernaut  that  the  idol  car  could  not  be 
dragged  about  as  usual.  In  1823,  Juggernaut  and  its  neighborhood  again 
suffered  severely.  In  1824  it  was  in  central  India  and  far  over  toward 
Bombay.  In  1825  it  was  again  at  Juggernaut  with  Calcutta  also  suffering 
severely.  Early  in  1826  it  was  evidently  on  the  increase  in  all  Lower 
Bengal.  By  May  13,  200  or  300  cases  died  per  day  at  the  holy  city  of 
Benares,  half  way  up  the  Ganges.  In  Xovember,  1826,  it  was  far  up 
above  Allahabad  on  both  the  Gauges  and  Jumna  rivers,  and  at  Delhi  and 
Agra.  In  May,  1827,  it  was  again  at  Agra  with  a  very  large  number  of 
victims,  and  in  June  again  in  and  around  Delhi  to  an  epidemic  extent. 
It  was  then  found  that  it  had  been  at  Hurdwar,  further  north,  in  April. 
In  June  it  had  spread  up  the  sides  of  the  Himalaya  mountains  to  the 
height  of  3,000  feet.  It  was  all  over  the  northAvest  provinces  in  1827, 
especially  at  Lahore,  one  of  the  most  northern  cities.  Suddenly  it  was 
heard  of  far  west  at  Teheran,  the  capital  of  Persia,  near  the  foot  of  the 
Caspian  sea,  but  not  until  early  in  1829.  Then  it  Avas  discovered  that  it 
had  been  at  Cabul  in  Afghanistan,  just  west  of  India,  in  1827  and  1828. 
Lieutenant  Connelly  met  with  it  at  the  important  city  of  Herat,  still  fur- 
ther Avest,  in  1828  and  1829,  and  said  that  cholera  had  swept  away  many 
thousands  of  persons  in  and  around  Herat. 

The  question  now  arises,  Hoav  did  cholera  get  to  Cabul,  Herat  and 
Teheran  ?  It  was  generally  assumed  that  it  was  blown  over  the  tops  of  the 
Himalaya  and  Suleiman  mountains.     But 

According  to  Lieutenant-colonel  Sir  Alexander  Bumes  (see  "Nari'atiA'e  of  a 
Journey  to  and  Residence  in  Cabul  in  1836,  '37  and  '38,"  p.  77),  the  most  extensive 
arrangements  liave  long  been  made  to  convey  pilgi'ims,  merchandise,  and  disease 
to  and  from  Hurdwar  and  Central  Asia. 

The  Lohanee  Afghans  are  a  migratory,  commercial,  and  pastoral  people 
who  proceed  annually  into  India  to  pm'chase  merchandise.  At  the  end  of  Octo- 
ber, as  winter  approaches,  they  descend  into  India,  remain  until  after  tiie  fair  at 
Hurdwar,  and  commence  their  return  toward  the  end  of  April.  They  all  reach 
Cabul  and  Candaliar  by  the  middle  of  Jvme,  in  sufficient  time  to  dispatch  their 
investments  to  Herat  and  Bokliara;  and  then  pass  on  into  Kliorassan  in  Persia, 
where  they  remain  during  the  summer.  They  marcli  in  three  great  divisions; 
the  first  has  twenty-foiu*  tliousand  camels;  the  second  nineteen  tliousand,  and  the 
third  seven  thousand.  It  is  witli  these  that  the  Hindoo  merchants,  and  foreigners 
generally,  travel.  This  channel  of  trade  is  very  ancient,  dating  before  the  time 
of  tlie  Emperor  Baber,  a.d.  1505. 

These   large  caravans  go  through  the  Bolan  and  Kyber  and   other 


THE  EPIDEMIC   OF  1837  TO   1833.  H 

mountain  passes  through  which  every  invasion  of  India  from  the  west  has 
taken  place.  Alexander  the  Great  and  his  Greek  troops  took  these  routes; 
also  Gengis-Khan,  and  all  the  Mohammedan  conquerors  of  India.  The 
English,  it  is  well  known,  have  made  several  invasions  of  Afghanistan 
through  them. 

The  arrangements  for  the  conveyance  of  pilgrims,  merchandise,  and 
disease  further  west  are  still  more  complete,  according  to  Sir  James  Con- 
nolly. Due  west  of  Herat,  lies  Meschid,  the  Holi/  City  of  Xorth  Persia. 
For  eight  months  in  the  year  all  the  roads  to  and  from  ]\Ieschid  are 
thronged  with  pilgrims.  Xearly  sixty  thousand  come  up  from  India, 
Cabul,  and  Afghanistan,  and  as  many  more  from  Turkey  in  Asia,  the  Cau- 
casus, and  shores  of  the  Black  and  Caspian  seas.  Meschid  lies  half  way 
between  Herat  and  Teheran. 

Herat  has  great  liistorical  and  present  interest.  The  Eussians  have  newly 
arrived  near  there.  It  is  surrounded  by  one  of  the  most  fertile  plains 
in  the  world,  about  forty  miles  in  diameter,  which  produces  grain,  cattle, 
fruits  and  vegetables  in  profusion.  It  is  watered  by  numberless  bright 
streams  and  rivulets,  antl  a  Jackass  load  of  grapes,  peaches,  melons,  etc., 
can  be  bought  for  50  cents.  An  army  once  there  will  require  nothing  but 
clothing,  arms  and  ammunition.  The  food  and  water  cpiestions  require 
no  attention.  Herat  has  been  visited  by  cholera  again  and  again.  In 
1828  King  Mohammed  and  Prince  Koursan,  the  last  members  of  the  royal 
family  of  Afghanistan,  fell  victims  to  cholera,  and  left  the  succession  in 
dispute  up  to  the  present  time. 

At  Teheran,  in  1829,  there  was  the  greatest  consternation.  The  Shah 
of  Persia  and  his  court  fled  to  the  mountains,  the  nobles  and  people  fol- 
lowed his  example,  to  escape  the  pestilence.  From  Teheran  cholera  was 
carried  for  the  second  time  to  and  up  the  Caspian  sea  to  Astrakhan  in  the 
north,  at  the  mouth  of  the  great  river  Volga,  where  it  empties  into 
the  Caspian ;  and  also  by  land  by  way  of  Tabreez  and  Tiflis,  and 
again  through  the  Pass  of  Dariel,  just  as  it  had  gone  before  in  1822  and 
1823. 

But  it  was  destined  to  reach  Orenburg  first,  high  up  on  the  Volga,  by 
another  route.  From  Herat  it  was  also  carried  northwest  by  caravans  to 
Balk,  and  Bokhara  the  most  holy  city  of  central  Asia,  and  is  even  said  to 
have  been  at  Cashgar  in  1827  and  1828.  Then  it  was  forwarded  to 
Khiva  on  the  sea  of  Aral,  and  from  thence  to  Orenburg,  which  is  the 
border  trading  town  of  Eussia.  and  also  a  strong  military  post.  It  had  a 
garrison  of  10,000  men  and  others  doing  outpost  duty  toward  Khiva.  The 
first  victim  on  Aug.  26,  1829,  was  a  soldier;  the  second  an  officer.  The 
Khurgis  tribes  who  brought  goods  with  caravans  seemed  to  escape,  and 
the  introduction  of  the  disease  seemed  a  mystery.  In  fact,  the  cases  were 
so  few  that  they  Avere  not  recognized  till  Sept.  10.  Finally  they  admitted 
that  it  had  raged  among  their  people,  and  it  came  out  finally  that  some 
of  them  had  died  of  cholera  in  Orenburg,  but  the  deaths  of  these  obscure 
people  were  easily  concealed.  Then  it  also  was  discovered  that  the  Khan 
of  Khiva  had  commenced  a  campaign  toward  Persia,  but  at  Khorassan 
had  been  compelled  to  retreat  on  account  of  an  outbreak  of  cholera  which 
swept  away  a  large  portion  of  his  army.  From  Sept.  9  to  Oct.  21,  1829, 
747  deaths  occurred  in  Orenburg.  At  first  it  was  supposed  not  to  be 
infectious  and  certainly  not  contagious;  but  it  was  inferred  that  well 
persons  coming  from  infected  districts  brought  some  of  the  atmosphere 
with  them  which  then  poisoned  the  air  of  the  new  place.      The  diarrhoeal 


12  ASIATIC  CHOLERA. 

origin  and  infection  were  overlooked;  soiled  clothes  were  not  examined  or 
looked  for,  Init  clean  merchandise  was  severely  quarantined. 

From  Orenburg  it  was  carried  Avest,  by  August  27,  1830,  to  the  great 
fair  of  Nishni  Novgorod,  where  300,000  to  400,000  merchants,  etc.,  as- 
semble in  July  and  August  of  every  year.  From  there  it  went  to  Mos- 
cow, to  which  it  was  also  coming  from  the  south,  from  Astrakhan,  and  up 
the  Volga,  spreading  over  all  southern  Russia  and  toward  Austria,  Hun- 
gary and  Poland. 

A  determined  effort  was  made  to  save  Moscow  by  means  of  quarantine 
and  cordons.  The  Emperor  of  Russia,  through  his  medical  advisers, 
announced  his  fullest  conviction  that  cholera  was  not  a  miasmatic  disease 
generated  in  the  soil  and  carried  about  by  the  winds,  but  by  persons  and 
soiled  clothing  only,  not  by  clean  merchandise  ;  that  it  spread  by  a 
species  of  infection,  then  called  contingent  contagion.  Twenty  cholera 
hospitals  were  provided,  one  for  each  ward  or  district  into  which  the  city 
was  divided,  with  police  officers,  physicians,  clergymen  and  a  magistrate 
for  each  section.  Barriers  were  placed  between  each  division,  so  that  if 
the  pestilence  broke  out  in  one  ward  it  might  be  prevented  from  spread- 
ing to  the  others.  Cholera  was  apparently  kept  out  of  Moscow  for  a  long 
time,  although  it  prevailed  in  every  province  around  it.  Finally  it  stole 
in  in  so  many  different  paths  by  means  of  diarrhoeal  cases  that  no  exact 
information  has  ever  been  gained  how  it  first  made  a  lodgment.  The 
people  took  alarm,  and  50,000  of  them  stole  away  before  stringent  measures 
Avere  instituted.  The  epidemic  Avas  Avell  under  Avay  by  Sept.  18,  1830, 
and  from  the  24th  to  28th  it  Avas  called  sporadic  and  indigenous  and  then 
all  means  for  preventing  its  entrance  after  it  had  long  been  in,  Avere  en- 
forced in  the  most  vigorous  manner,  and  also  to  keep  a  pestilence  in  Avhicli 
had  already  got  out.  A  double  military  cordon  Avas  put  around  the  city, 
Avith  troops  and  loaded  cannon  cA'eryAAdiere;  all  the  bridges  were  destroyed, 
and  Avagons,  horses,  and  vehicles  seized.  Infected  persons  Avere  isolated ; 
their  clothes  washed  in  chlorine  Avater  or  vinegar,  and  fumigated  Avitli 
burning  sulphur.  The  physicians  Avashed  their  hands  and  faces  Avith 
A'inegar  and  rinsed  their  mouths  Avith  it;  Avere  careful  not  to  sAA'alloAv  their 
saliA'a,  and  breathed  through  sponges  soaked  in  vinegar  Avhen  in  the  vicin- 
ity of  severe  or  fatal  cases.  Tlie  physicians  generally  escaped,  but 
ninety-three  clergymen  died.  Nearly  9,000  cases  in  all  occurred,  for  they 
did  not  then  knoAv  hoAv  to  disinfect  the  discharges. 

From  Moscow  it  was  also  carried  to  St.  Petersburg,  on  the  26th  of 
June,  1831,  and  Drs.  Russell  and  Barry,  of  the  Indian  service,  Avho  had  been 
familiar  with  cholera  in  Ilindostan,  Avere  sent  by  the  English  Government 
to  observe  the  disease.  A  triple  cordon  of  troops  Avas  placed  around  St. 
Petersburg  to  keep  out  the  cholera;  but  Drs.  Russell  and  Barry  state  that 
the  first  case  occurred  in  a  person  who  came  down  the  river  NcA^a,  in  a 
bark  Avith  goods  from  Moscoav;  the  second  in  an  individual  Avho  had  been 
on  board  the  bark  upon  its  arriA'al;  and  the  third  in  a  soldier  AAdio 
had  mounted  guard  on  the  boat  to  prevent  any  intercourse  Avith  the 
shore.  From  St.  Petersburg  it  Avas  carried  doAvn  to  Cronstadt.  on  the 
Baltic,  and  a  ncAv  current  of  the  disease  was  then  let  loose  to  visit  Ham- 
burg, Bremen  and  England.  The  Avinds  had  bloAvn  east  to  St.  Peters- 
burg for  51  days,  Avest  32  days,  and  variably  9  days.  The  east  Avind  was 
accused.  St.  Petersburg  had  no  seAvers  at  that  time,  and  got  most  of  its 
drinking  Avater  from  contaminated  surface  Avells.  The  people  understood 
this  so  Avell  that  they  accused  the  government,  doctors,  apothecaries,  Jcavs, 


THE  EPIDEMIC  OF   1837   TO   1833.  13 

and  all  strangers  of  poisoning  tlie  wells.  Huge  riots  broke  out  in  wliicli 
many  doctors  were  injured  and  some  killed.  Finally  nearly  10,000  of  the 
lower  classes  broke  the  cordon  and  spread  themselves  over  the  country, 
sometimes  carrying  the  disease  with  them.  Finally  it  got  up  as  high  as 
Archangel  on  tlae  White  sea  and  Frozen  ocean. 

In  the  meantime  the  great  Polish  insurrection  of  1830  had  taken  place, 
and  Russian  troops  from  many  infected  provinces  had  been  sent  to  the 
neighborhood  of  Warsaw.  Many  battles  took  place,  in  some  of  which  the 
Poles  beat  the  Russians,  took  possession  of  their  infected  camp-grounds, 
and  captured  arms,  food  and  clothing.  It  then  commenced  in  the  Polish 
army,  which  was  finally  beaten  back  to  Warsaw,  introducing  the  disease 
there. 

Almost  the  whole  of  the  Prussian  and  Austrian  armies  were  employed 
in  huge  cordons  against  the  cholera  in  Russia  and  Poland,  but  people  were 
seen  running  the  lines  and  were  fired  upon  every  night.  In  addition, 
Prussia  allowed  Dantzic  to  be  used  as  a  depot  of  provisions  and  stores  for 
the  Russian  army,  and  its  harbor  was  crowded  with  Russian  transports. 
It  is  needless  to  say  that  cholera  broke  out  badly  in  Dantzic. 

To  complete  the  folly,  the  whole  Polish  army  finally  crossed  the  boun- 
daries of  Austria  and  Prussia,  laid  down  its  arms,  and  surrendered  to  them 
rather  than  to  the  Russians.  Cholera  was  quickly  in  Hungary  and  Aus- 
tria, but  especially  it  was  carried  to  Berlin  and  from  there  to  Hamburg 
and  Bremen,  and  from  thence  over  to  England.  Still  it  was  not  des- 
tined to  reach  England  first  in  that  way. 

From  Moscow  it  was  conveyed  early  in  May,  1831,  to  Riga,  and  it  is 
distinctly  stated  that  it  was  brought  to  the  headwaters  of  the  river  Duna, 
at  the  mouth  of  which  Riga  is  situated,  and  was  carried  downstream 
to  that  city.  Immense  alarm  arose,  and  on  June  3d  no  less  than  sixty 
vessels  fled  in  haste  from  Riga,  four  of  which  were  destined  for  England, 
es];)ecially  for  Sunderland,  on  the  east  coast.  By  October  26,  1831,  an 
official  English  report  declared  that  three  hundred  and  six  cases  and  ninety- 
four  deaths  had  already  occurred  in  Sunderland,  and  the  first  case  of 
cholera  in  London  occurred  in  the  person  of  a  man  from  Sunderland, 
From  London  it  was  carried  to  Dover,  and  over  to  Calais  and  Paris,  in 
France.  From  England  it  was  carried  to  Scotland  and  Ireland,  and  in  the 
spring  of  1832  vessels  from  Dublin  and  Cork  conveyed  the  disease  over 
the  Atlantic  to  Quebec, 

Greville,  secretary  of  the  Privy  Council  of  England,  was  sent  up  to 
Sunderland  to  obtain  information,  which  he  says  it  was  very  difficult  to 
procure.  The  medical  men  and  higher  classes  Avere  split  into  parties, 
quarreling  about  the  nature  of  the  disease  and  concealing  the  facts  which 
militated  against  their  respective  theories.  Dr.  Danby,  the  health  officer, 
complained  that  physicians  would  send  him  no  information,  and  a  strong 
government  order  Avas  put  forth  to  compel  them.  He  winds  up:  "For 
a  long  time  the  truth  was  quite  unattainable  in  Sunderland,  Falsehood 
was  propagated  Avitli  such  zeal  in  every  quarter  that  the  medical  and  daily 
press  were  almost  universally  imposed  upon."  A  trunk  of  clothes  belong- 
ing to  a  siiilor  Avho  died  of  cholera  at  Riga  on  the  Baltic  was  sent  to  his 
home  in  Elaine;  the  contents  were  given  to  his  relatives,  some  of  whom, 
according  to  the  late  Dr.  C.  A,  Lee,  died  of  cholera  in  that  State, 

In  Sunderland  the  fiercest  disputes  arose  about  the  origin  and  mode 
of  arrival  of  the  disease.  It  Avas  knoAvn  that  some  Sunderland  sailors 
had  died  in  Baltic  parts  on  board  of  coal  vessels,  and  their  clothes  had  been 


14  ASIATIC  CHOLEEA. 

sent  back.  The  first  persons  attacked  in  the  port  resided  on  the  quay 
and  were  exposed  to  intercourse  witli  the  shipping.  It  was  subsequently 
proved  that  cases  had  occurred  as  far  back  as  the  5th,  1-lth,  and  29th  of 
August,  and  were  not  reported,  or  were  concealed.  This  was  two  months 
before  the  acknowledged  importation  of  the  pestilence. 

There  were  only  97  deaths  in  all  England  in  November,  1831;  282  in 
December;  614  in  January,  1832;  708  in  February;  1,519  in  March;  and 
1,101  in  April. 

The  emigration  to  Canada  and  New  York  was  so  great  in  1832  that 
cholera  reached  both  these  distant  places  almost  before  it  was  carried  from 
London  down  to  Paris.  On  March  24,  1832,  cholera  broke  out  suddenly 
in  Paris,  and  according  to  M.  Gendrin,  on  the  third  day  of  its  appearance 
he  received  patients  from  many  districts  in  Paris  into  the  Hotel  Dieu. 
He  observes  that  the  patients'  distant  residences  and  opposite  professions 
precluded  the  probability  of  their  having  derived  their  disease  by  con- 
tagion, or  from  human  contact.  The  disease  was  so  virulent,  that  of  the 
first  98  cases  96  died.  Within  a  week  the  mortality  reached  500  a  day, 
and  the  cases  to  four  times  that  amount,  and  in  eighteen  days  no  less  than 
r,000  persons  had  died  of  it.  To  every  one  conversant  with  cholera  this 
tremendous  outbreak  was  not  brought  to  it  by  the  winds,  but  was  cer- 
tainly connected  with  water  contaminated  with  cholera  discharges  and 
filth.  It  also  goes  without  saying,  that  it  did  not  reach  its  great  propor- 
tions in  three  days.  In  fact  it  commenced  as  early  as  March  1st,  which 
was  no  fool's  day  for  Paris.  Grisqiiet,  the  Prefect  of  Police,  exerted 
himself  to  suppress  the  j)estilence,  but  the  rag-pickers  rebelled  against  the 
order  forbidding  garbage,  dirt  and  rubbish  being  thrown,  as  usual,  in  the 
streets  and  raised  barricades.  Others  thought  the  disease  was  brought 
and  propagated  by  the  government,  aided  by  physicians  and  apothecaries, 
and  the  latter  were  insulted  and  assaulted.  In  fact,  the  pestilence  had 
been  spreading  slowly  for  six  weeks  before  the  great  outburst,  the  cause 
of  which  has  only  been  made  manifest  by  Dr.  Marey  in  his  little  brochure 
called  "  Les  Eaux  Contaminees  et  le  cholera.  Paris  1884."  He  marked 
on  a  plan  of  Paris  every  house  which  had  had  deaths  from  cholera,  and 
then  hunted  up  the  water-supply.  The  left  bank  of  the  Seine  suffered 
slightly,  the  right  severely;  the  latter  was  supplied  largely  from  the  canal 
deL'Ourcq  and  the  river  Seine.  The  former  at  La  Villette  is  exceeded 
in  its  amount  of  market  boats  and  shipping  only  by  Marseilles  and  Havre, 
all  the  filth  of  which  goes  into  the  canal;  the  water  is  filthy  dock  water; 
in  addition  many  sewers  empty  into  the  canal,  as  others  do  into  the  Seine, 
and  yet  this  nasty  water  was  supplied  to  the  gi'eater  part  of  Paris  for 
drinking  and  cooking.  In  every  epidemic  in  Paris,  even  that  of  last  year, 
1884,  the  canal  de  L'Ourcq  has  played  the  same  distinctive  part. 

In  all  the  epidemics  in  Paris  and  many  other  places  the  most  wearisome 
and  complicated  tables  are  given  of  the  age,  sex  and  occupation  and  married 
or  single  state  of  the  sufferers,  the  state  of  the  thermometer  and  barometer, 
the  direction  and  strength  of  the  winds;  the  amount  of  heat  and  rainfall; 
even  the  side  of  the  house  and  the  story  in  which  the  patient  dwelt;  the 
nature  of  the  soil,  etc.,  etc.  All  of  which  gives  scarcely  a  gleam  of  the 
nature  and  causes  of  cholera.  Fortunately  the  amount  and  kind  of  civic 
filth  is  often  given,  and  occasionally  a  hint  that  the  water  supply  was  bad. 
All  the  early  cases  in  Paris  were  overlooked  or  concealed,  and  it  has  never 
been  made  known  how  the  pestilence  arrived  there.  It  was  at  Calais, 
from  England,  before  it  reached  Paris  and  probably  also  in  Havre  from 


THE  EPIDEMIC   OF  1827  TO   1833.  X5 

Hamburg.  Of  20,000  inhabitants  in  the  Luxemburg  quarter  7,552  were 
indigent  and  13,330  well-to-do.  Of  the  former  4,500  suffered  from 
cholera;  of  the  latter  only  2,500.  Before  the  advent  of  the  epidemic 
in  France  it  was  reproduced  in  England  and  Ireland,  esj^ecially  in  Hull, 
York  and  Leeds,  but  there  were  only  14,796  cases  and  5,432  deaths. 

I  will  finish  with  the  epidemic  in  Europe  before  following  it  to 
America.  L^p  to  this  time  Spain  and  Portugal  had  escaped:  then,  the 
London,  a  transport  steamer,  sailed  from  England  to  Oporto,  on  Dec. 
25,  1832,  with  troops  for  Gen.  Polignac:  not  a  nice  Christmas  gift,  and 
arrived  on  Xew  Year's  day,  1833,  having  lost  seven  men  by  cholera;  the 
disease  appeared  on  land  on  Jan.  15th.  Spanish  quarantine  was  rigorously 
enforced,  except  among  the  troops.  Every  other  traveler  from  the  in- 
fected district  was  detained,  and  even  threatened  with  death  and  confis- 
cation of  goods,  if  he  did  not  go  through  all  the  formalities;  and  also  all 
those  who  harbored  him.  But  cholera  broke  out  soon,  of  course,  in  many 
provinces  in  Spain,  reached  Madrid,  and  was  even  carried  over  to  Barcelona 
on  the  east  coast. 

In  the  meantime  it  had  been  brought  down  from  Paris  to  Marseilles 
and  Toulon,  and  also  forwarded  east  to  Villafranca,  Xice  and  Cannes. 
By  August  12th  it  was  at  Turin  and  soon  after  at  Genoa  on  the  west  coast 
of  Italy.  By  November,  1834,  it  had  reached  A'enice  and  Trieste  on  the 
east  coast  and  the  Adriatic  sea.  In  October,  1836,  it  appeared  in  Naples 
in  spite  of  a  most  rigid  quarantine  at  the  port,  but  it  slipped  in  overland, 
from  Milan  and  other  places.  The  physicians  traversed  the  streets  covered 
from  head  to  foot  Avith  black  wrappers  of  wax  cloth  into  which  two  pieces 
of  glass  were  introduced  for  eye-holes.  In  Rome  alone  there  were  9,372 
cases  and  4,519  deaths. 

It  soon  spread  down  to  Sicily,  and  is  supposed  to  have  been  carried  east 
to  Malta,  on  June  9th,  1837,  followed  by  3,893  deaths  among  the  people 
and  815  cases  and  578  deaths  in  the  English  garrison  of  3,070  men.  The 
Mediterranean  fleet  suffered  considerably,  but  only  after  it  had  touched  at 
Palermo  or  Malta. 

But  another  stream  of  the  disease,  which  had  been  overlooked,  was 
coming  up  from  Mecca  as  early  as  1831,  brought  there  from  India.  Xearly 
one-half  of  the  pilgrims  died,  especially  in  the  Sp'ian  caravan,  and  the 
governors  of  Mecca  and  Jeddah,  the  seajiort  of  Mecca.  It  was  carried  up 
to  Suez  and  Cairo  in  Egypt,  and  from  there  to  Alexandria  on  the  Medi- 
teranean  in  August;  and  had  also  been  pushed  up  the  old  route  to  Asia 
Minor.  In  July  it  was  at  Constantinople,  whether  brought  up  from 
EgA^i^t,  or  over  from  southern  Eussia,  or  both,  no  one  knows.  But  this 
much  is  certain,  that  it  almost  reached  Vienna  from  the  west  by  way  of 
France  and  Italy,  almost  before  it  got  there  from  the  east  by  way  of  Rus- 
sia; so  that  at  this  early  date  there  was  no  excuse  for  assuming  that  cholera 
always  traveled  west  like  the  young  man;  especially  as  it  was  known  that 
it  had  been  carried  east  to  Cluua  as  early  as  1821. 


X(j  ASIATIC  CHOLERA. 


CHAPTER  IV. 

THE  FIRST  EPIDEMIC  IN  THE  UNITED  STATES,  THAT  OF  1833. 

Cholera  had  ])revailed,  as  we  have  seen,  in  Enssia  in  1829  and  1830. 
Tt  reached  England,  Scotland  and  Ireland  in  1831,  and  Avas  first  landed 
at  Grosse  Island,  the  qnarantine  station  for  Quebec,  on  April  28,  1832, 
by  the  ship  Constantia  from  Limerick,  Ireland,  Avith  170  emigrants,  of 
whom  29  had  died  of  cholera  on  the  voj^age.  On  ]\Iay  llth,  the  ship  Robert, 
from  Cork,  arrived,  having  had  10  deaths  from  cholera.  On  May  28th 
the  ship  Elizabeth,  from  Dublin,  came  in  with  200  passengers,  and  20 
deaths  from  cholera.  On  June  3d  the  brig  Carrick,  from  Dublin,  followed 
with  145  emigrants  and  42  deaths  from  cholera.  Total,  375  emigrants 
and  159  deaths  from  the  pestilence.  There  Avas  no  proper  quarantine,  all 
Avho  seemed  well  Avere  forAvarded  at  once  from  Grosse  Island.  The  soiled 
clothing  Avas  not  Avashed,  and  disinfection  was  unknoAvn.  There  Avas  con- 
stant and  uninterrupted  intercourse  by  sailing  and  steam  vessels,  which 
took  off  all  AA'ho  Avanted  to  go  from  the  quarantine  to  Quebec  and  even  to 
Montreal.  So  energetically  Avas  this  done  that  from  June  2d  to  5tli  no 
less  than  750  emigrants  had  been  taken  from  Grosse  Island  to  Quebec  and 
some  to  Montreal,  and  before  the  end  of  the  summer  nearly  30,000  Avere 
forAvarded  up  the  river  St.  Lawrence.  Deaths  Avere  of  course  so  common 
that  no  special  attention  was  paid  to  cholera  or  any  other  disease.  So 
little  did  the  Canadian  authorities  knoAV  about  Avhat  Avas  going  on,  that 
they  long  attributed  the  Avhole  outbreak  to  the  brig  Carrick,  and  fixed 
the  3d  day  of  June  as  the  date  of  the  first  case  of  cholera  in  Xorth  America. 

A  glance  at  any  school  map  will  shoAv  that  no  winds  except  exceed- 
ingly intelligent  ones  could  have  bloAvn  cholera  from  England  and  Ireland 
to  Quebec  Avithout  first  attacking  Kova  Scotia,  Prince  EdAvard's  Island, 
XeAvfoundland,  Anticosti,  Xcav  BrunsAvick,  some  jwrt  of  ^Maine,  or  of  East 
Canada  before  reaching  Quebec;  nor  could  they  have  pursued  a  directly 
nortliAvest  course  up  the  Gulf  of  St.  LaAvrence  to  latitude  49°  and  then 
suddenly  have  turned  doAvn  the  river  St.  LaAvrence  due  southwest,  Avith- 
out the  aid  of  pilots,  helmsmen  and  ships. 

Up  to  September  2d  there  were  2,208  deaths  from  cholera  in  Quebec, 
of  Avhich  56  occurred  in  the  first  two  weeks  of  June  in  Eoache's  emigrant 
boarding-house.  Again  it  is  generally  supposed  that  the  steamboat  Yoya- 
geur  carried  cholera  from  Quebec  to  Montreal  b}'^  June  9th;  but  we  have 
seen  that  cases  were  sent  there  before  that,  and  the  Montreal  officials  kncAv 
as  little  about  its  commencement  as  did  those  of  Quebec.  In  the  first  tAvo 
weeks  there  Avere  800  deaths,  and  by  September  1st,  1,843. 

From  the  St.  LaAvrence  the  disease  Avas  forAvarded  along  Lake  Ontario 
by  steamboats,  and  by  land  along  its  northern  or  Canadian  border.  Those 
places  Avhere  no  passengers  Avere  alloAved  to  land  escaped.     From  Montreal 


CHOLERA  IN  NEW  YORK  IN  1832.  17 

the  pestilence  commenced  to  descend  Lake  Champlain  by  means  of  emi- 
grants and  travelers  toward  Albany  and  New  York.  Every  eye  was  turned 
toward  Canada,  when  suddenly  it  appeared  in  the  city  of  New  York  on 
June  2-l:th,  before  it  could  easily  be  traced  to  any  arrival  from  Canada, 
although  the  arrival  of  trunks  from  Leeds,  Canada,  was  subsequently 
reported.  If  it  did  not  come  from  Canada  it  would  have  required  the 
same  wonderful  intelligence  on  the  part  of  the  winds  to  blow  cholera  past 
New  Jersey,  Long  and  Staten  Islands,  Brooklyn  and  Jersey  City,  into  the 
heart  of  the  lower  and  east  part  of  the  city.  All  the  records  of  the  arrival 
of  ships  at  New  York  during  April,  May  and  June,  1832,  have  been 
removed,  while  those  before  and  after  are  complete.  Dr.  Vache  and  Dr. 
Alonzo  Clark  state  that  a  cholera  ship  arrived  at  New  York  in  June. 
The  sick  were  cared  for  at  the  quarantine,  and  the  well  were  shipped  to 
the  city  and  up  the  North  Eiver  as  rapidly  as  possible.  There  was  a  race 
of  cholera  from  Canada  and  New  York  city  to  Albany,  which  it  reached 
July  3d  and  finally  caused  1,10-i  cases.  By  July  12tli  it  was  at  Schenec- 
tady coming  from  Albany;  and  on  the  same  date  at  Eochester  from  New 
York.  July  15th  it  was  at  Buffalo  among  canal  boatmen,  and  among  emi- 
grants by  the  30th. 

Cholera  ix  New  York  City  in  1833. 

New  York  city  should  have  been  well  prepared  for  the  reception  and 
proper  management  of  cholera,  but  it  committed  almost  every  mistake  of 
ignorance  and  prejudice,  or  worse,  that  has  ever  been  promulgated.  The 
diarrhoeal  commencement  of  the  disease  was  already  well  known,  but  it 
was  assumed  that  the  pestilence  was  in  the  air  and  not  in  the  bodies  and 
discharges  of  the  sick.  Because  it  was  not  directly  and  immediately 
contagious  it  was  declared  not  to  be  even  infectious.  Although  it  was  a 
specific  and  most  peculiar  disease,  it  was  asserted  that  all  its  causes  were 
only  merely  those  of  common  diarrhoea,  and  ordinary  cholera  morbus. 

In  the  official  report  every  fanciful  notion  was  jumped  at,  and  all  the 
most  patent  facts  overlooked.  It  was  asserted  that  easterly  and  south- 
easterly winds  had  prevailed  in  Canada  and  brought  the  disease  across  the 
ocean.  That  influenza  had  prevailed  in  1831  and  foreshadowed  cholera, 
especially  as  aged  and  weak  people  could  not  bear  full  doses  of  Tartar 
emetic.  That  scarlet  fever  was  malignant  and  often  attended  with 
diarrhoea.  That  intermittent  fevers  were  common  in  the  lower  parts  of 
the  city,  and  sometimes  showed  great  prostration  and  even  collaj)se,  Avhen 
they  were  of  the  congestive  kind.  That  cholera  morbus  and  dysentery 
occurred  in  the  winter  in  unusual  proportions,  and  the  air  was  evidently 
taking  on  an  epidemic  choleraic  constitution.  That  on  July  IGth  vomit- 
ing, diarrhoea  and  cramps  appeared  among  a  tribe  of  Indians  100  leagues 
from  the  sea,  when  the  true  disease  had  been  in  the  country  for  more  than 
two  months.  That  attempts  to  trace  cholera  to  vessels  at  Quebec  were  not. 
successful,  although  the  first  cases  Avere  among  emigrants;  this  was  attrib- 
uted not  to  infection,  but  solely  to  the  crowded  and  filthy  condition  of  the- 
emigrant  houses;  for  did  not  the  pestilence  break  out  in  a  low  and  un- 
cleanly and  ill-ventilated  part  of  the  city  of  Quebec,  then  crowded  with 
a  large  population  of  emigrants  of  the  lowest  description.  The  sickness: 
on  board  the  Carrick  and  other  cholera  vessels  Avas  declared  to  have  been 
mainly  ship-fever  and  small-pox;  and  although  there  had  been  some 
cholera  on  board  these  vessels,  yet  there  had  been  no  cases  for  thirty 


l^  ASIATIC  CHOLERA. 

days  previous  to  the  arrival  of  some  of  them.  In  the  first  two  Aveeks, 
(more  correctly  months)  there  had  been  1,000  deaths,  which  excessively 
large  number  could  only  have  come  from  a  general  distemperature  of  the 
air,  which  spared  1,000  where  it  attacked  one.  The  conveyance  by  soiled 
clothing  was  overlooked. 

In  Montreal  great  stress  was  laid  on  the  fact  that  on  the  same  night  of 
June  9th,  when  the  Voyageur  arrived,  several  native  inhabitants  sickened  in 
various  jjarts  of  the  city  remote  from  the  docks  and  from  each  other,  be- 
fore having  had  communication  with  the  port  or  landing  place,  and  most 
if  not  all  of  these  died  in  twenty-four  hours;  but  we  have  already  seen  that 
cholera  was  landed  April  28th,  May  14th,  May  28th,  and  June  3d.  The 
Voyageur  we  now  know  was  not  the  first  steamboat  laden  with  cholera 
which  went  from  Grosse  Island  and  Quebec  to  Montreal.  Many  diarrhceal 
cases  had  been  landed  and  had  wandered  all  over  Montreal,  or  many 
parts  of  it.  In  two  weeks,  or  more  likely  two  months,  800  persons  died 
of  it,  and  this  so-called  rapidity  of  generation  and  progress  is  erroneous]}^ 
said  to  have  outstripped  the  emigrants  and  reached  Detroit  early  in  July. 
But  we  noAV  know  the  very  steamboats  bv  which  it  was  carried  to  Detroit. 

Again,  it  is  incorrectly  stated  that  without  having  shown  itself  at  any 
intermediate  spot  between  Canada  and  New  York  it  appeared  in  New 
York  city  in  the  i^erson  of  a  Mr.  Fitzgerald,  an  Irish  emigrant,  who 
arrived  in  Quebec  in  the  autumn  of  1831,  and  lived  in  Albany  from  Sep- 
tember to  May,  and  on  the  3d  of  Ma}'  took  a  first  floor  of  a  house  in  Cherry 
street,  near  James  street.  He  was  a  steady  and  temperate  tailor,  his  wife 
was  a  neat  housekeeper,  and  they  committed  nOj  imprudence  in  diet.  On 
June  25th  he  spent  the  day  in  Brooklyn,  sickened  in  the  night,  but  soon 
recovered.  Early  on  the  26th  two  of  his  children  were  attacked,  and  both 
died  on  the  2Ttli.  On  the  28th,  after  eating  strawberries  and  being  ex- 
posed to  the  infection  of  her  husband  and  children,  who  had  not  eaten 
strawberries,  the  wife  was  attacked  and  died. 

Fitzgerald  is  the  man  who  is  said  to  have  received  a  trunk  of  soiled 
clothing  from  Leeds,  Canada,  although  some  say  it  came  from  Leeds,  Eng- 
land; he  was  a  recent  emigrant,  and  may  have  had  close  connections  Avitli 
Canada  and  even  Ireland  or  England.  It  is  certain  that  his  diet  and  sur- 
roundings did  not  cause  Asiatic  cholera,  which  had  already  been  quietly 
and  secretly  introduced  into  Xew  Y^'ork  by  the  ship  Henry  IV.  and  others. 

The  second  reported  case  in  New  Y^ork  was  also  an  Irishman  named 
O'Neil,  seized  the  same  day  in  Greenwich,  two  miles  away  from  the  first 
cases.  l%e  died  the  next  day  in  the  Greenwich  hospital.  He  had  been 
drunk  fOr  a  week  and  had  fallen  into  the  North  liiver,  jjerhaps  where 
some  cholera  ship  had  docked.  The  next  day,  June  30tli,  a  lodger  of  a 
Mr.  Haunasy,  No.  15  James  slip,  near  the  first  cases,  Avas  seized  and 
died  July  1st.  He  was  temperate  and  careful,  but  was  not  known  to 
have  had  any  communication  Avith  the  first  James  street  cases.  Another 
lodger  sickened  and  died  the  same  day  in  the  same  house  July  1st. 
The  keeper,  Mr.  Hannasy,  and  several  otliers  Avere  subsequently  taken 
sick  and  died  either  there  or  at  places  to  which  they  Avere  removed.  All 
the  latter  were  intemperate,  and  the  house  Avas  most  disgustingly  filthy; 
but  those  causes  alone  could  not  produce  Asiatic  cholera;  while  the  signs 
of  infection  Avere  very  manifest. 

On  July  2d,  cases  (Iioav  many?)  occurred  near  the  same  locality,  viz., 
in  Water  street,  on  the  East  river,  near  James  street.  By  July  4th  it 
had  shown  itself  in  various  places  upon  the  opposite  or  west  side  of  the 


CHOLERA  IN  NEW  YORK  IN  1832.  19 

city.  From  this  time  cases  continued  to  mnltipl}'  daily,  and  Dr.  Dudley 
Atkins,  secretary  to  the  special  cholera  medical  council,  hardily  says, 
"All  efforts  to  trace  these  cases  among  Irishmen  to  any  foreign  source 
have  thus  far  been  wholly  unsuccessful. " 

By  July  3d  public  alarm  was  excited  to  the  highest  degree  and  a  special 
medical  council  was  appointed  and  continued  to  serve  until  the  decline 
of  the  epidemic.  This  council  consisted  of  Dr.  Alexander  H.  Stephens, 
President;  Drs.  Joseph  Bayley,  Gilbert  Smith,  John  Xeilson,  Wm.  J. 
MacNeven,  Hugh  McLean,  "Eichard  K.  Hoffman  and  Anthony  L. 
Anderson.  ^Ye  will  soon  see  how  they,  and  perhaps  the  secretary,  were 
misled  by  the  Common  Council.  The  Kecord  office  in  the  Park  was  turned 
into  a  cholera  hospital,  and  in  nine  weeks  from  July  1st  to  Sej)t  1st  there 
were  "2,030  patients  and  852  deaths  there,  with  1,189  recoveries.  Medical 
stations  were  appointed  in  each  ward.  About  Jnly  1st  the  disease  appeared 
at  the  Almshouse,  Bellevue,  but  cases  of  a  so-called  doubtful  nature  had 
occurred  in  June,  but  were  not  seen  by  the  house  physicians,  as  they  were 
only  paupers.  These  first  doubtful  cases  were  in  all  parts  of  the  Alms- 
house quite  distant  from  the  ward  in  which  the  case  of  Jvily  1st  occurred; 
so  that  the  whole  house  was  already  infected.  In  all  there  were  precisely 
555  cases  and  exactly  300  deaths,  neither  more  or  less,  according  to  these 
so-called  accurate  figures. 

Dr.  Thomas  T.  Devan  was  the  physician  of  the  Bellevue  cholera  hos- 
pital; from  his  report  we  learn  that  the  first  case  was  brought  there  in  the 
person  of  Joseph  Dean,  colored,  aged  16,  who  had  been  sweeping  streets 
in  the  first  ward  of  the  city,  and  was  admitted  to  the  Almshouse  not  on 
July  1st,  but  on  June  25th,  about  dusk,  having  sickened  with  diarrhoea 
on  the  18th  or  19th.  He  was  sent  to  BlackwelFs  Island,  where  he  re- 
covered, and  no  other  cases  occurred  on  that  Island  till  July  10th. 

On  June26tli,  Eichard  Bostwick,  colored,  aged  S3,  who  had  been  lying 
in  the  same  ward,  viz.,  Xo.  3,  of  the  Almshouse  in  which  Dean  had  been 
23ut,  was  attacked  with  vomiting,  purging  and  cramps,  and  died  next  day. 
He  was  an  old  resident,  had  been  in  the  Almshouse  since  1829,  and  was 
long  supposed  to  have  been  the  first  case,  who  had  been  nowhere  and 
done  nothing  to  bring  on  cholera,  which  had  been  blown  in  the  windows 
as  they  were  open  during  the  day,  though  shut  at  night.. 

The  third  case  in  the  Almshouse  was  on  June  27th,  and  the  next  two 
on  July  1st,  in  room  19.  Then  the  disease  began  to  show  itself  in  every 
part  of'  the  Almshouse;  no  place  except  room  4  escaping  its  ravages. 
Total  to  August  10,  5-47  cases,  315  deaths,  and  232  cures. 

Dr.  Joseph  Bayley  of  the  special  medical  council  was  appointed  to 
investigate  the  outbreak  in  the  Almshouse,  and  incorrectly  says  the  first 
case  was  Mary  Bloomfield  in  ward  19,  who  sickened  July  1st,  and  died 
on  the  2d.  She  had  not  been  in  New  York  city  for  several  years,  but  it  was 
not  ascertained  whether  she  had  received  visitors  from  the  city;  still  5-4 
persons  had  been  taken  in  the  Almshouse  from  June  24th  to  Jvily  1. 
After  her  death  two  other  women  occupying  adjoining  beds  to  Mary,  and 
who  had  been  in  the  city,  also  sickened  and  died,  as  did  the  nurse,  who 
had  not  been  in  town.  Here  are  all  the  signs  of  infection,  which  has  been 
strenuously  denied  to  this  day.  Mary  doubtless  contracted  her  cholera 
from  the  women  who  had  been  in  the  city,  and  being  weaker,  merely  died 
sooner. 

Again,  Daniel  Evan  was  sent  from  the  Almshouse  to  the  general  hospi- 
tal of  Bellevue  on  July  3d,  and  died  the  next  morning.    Also  George  Elliott 


2(3  ASIATIC  CHOLERA. 

and  George  Riley,  who  had  been  f  rohcking  abont  the  city  on  July  4th,  were 
sent  to  the  Almshouse  July  5th,  rallied,  and  then  drank  cold  water  and 
died.  Then  Joseph  Herring,  in  hospital  from  April  9th  for  chronic 
diarrhoea,  but  sleeping  between  Ryan  and  Elliott,  died  on  the  same  day, 
July  7th,  that  he  was  attacked.  Then  Catharine  O'Neal,  sister  perhaps 
of  the  second  city  case,  had  been  a  few  days  in  the  city,  returned  to  the 
Almshouse  June  30th,  and  was  sent  from  there  to  the  hospital,  where  she 
died  July  3.  Then  Ann  Barnes,  sent  from  the  Almshouse  July  4th,  died 
on  the  5th.  The  first  resident  living  in  the  hospital  attacked  had  been 
there  from  April  25th,  was  seized  July  6th,  a'fter  Catharine  and  Ann  had 
been  admitted,  and  she  died  next  day,  followed  to  the  grave  by  several 
other  female  patients. 

It  has  always  been  erroneously  maintained  that  all  the  first  victims  in 
the  Bellevue  Almshouse  were  old  residents:  that  no  new-comers  were 
attacked;  that  the  infection  was  not  brought  by  persons  or  things  into  the 
Almshouse  or  hospital,  but  was  blown  in  by  the  winds  and  the  general 
distemperature  of  the  air;  in  proof  of  which  the  exact  size  of  the  doors 
and  windows  were  carefully  given,  and  the  size  of  the  chimneys. 

When  one  can  get  at  all  the  facts,  most  all  of  the  mysteries  about 
the  introduction  of  cholera  into  hospitals  and  prisons  can  be  easily  cleared 
up;  or  rather  they  clear  themselves  up. 

Dr.  Bayley  curiously  enough  omits  all  the  cases  before  July  1st,  and 
says:  "  From  the  1st  to  the  8tli  of  July,  eight  days,  there  were  G8  cases. 
From  the  9th  to  the  16th,  also  eight  days,  278  cases.  From  the  17th  to 
the  24th,  also  eight  days,  only  96  cases. '^ 

Not  the  least  ray  of  light  was  shed  upon  this  tremendous  multiplication 
of  the  disease.  There  must  have  been  water  contamination;  but  not  a 
word  is  said  about  the  water  supply.  The  Croton  aqueduct  was  not 
completed  until  1843.  Bad  well  or  pump  water  must  have  been  used. 
There  were  no  sewers,  and  out-door  privies  must  have  existed;  how  near 
the  wells  they  were  no  one  now  knows;  night  pails  were  probably  used 
in  the  sick  wards,  and  a  ftecal  atmosphere  pervaded  them. 

To  return  to  New  York  city:  Dr.  Atkins  says:  "  The  disease  was  of  an 
atmospheric  character,  caused  by  a  general  distemperature  of  the  air,  yet 
it  was  confined  for  the  most  part  to  a  few  portions  of  the  city,  so  that 
there  were  definite  and  limited  or  localized  neighborhoods,  which  were  to 
a  remarkable  degree  more  sickly  than  others.  Of  these  the  Five  Points, 
a  resort  of  the  vicious  and  dissolute,  was  most  heavily  visited.  This  was 
originally  a  swamp,  and  although  filled  in,  must  be  low  and  damp,"  and 
cholera  hence  was  primarily  malarious.  The  other  parts  of  the  city  where 
the  pestilence  chiefly  prevailed  were  low,  dirty  and  unhealthy,  with  narrow 
streets  and  filthy  dwellings,  inhabited  by  the  lowest  and  poorest  people. 
Duane  and  Vestry  streets  escaped,  and  as  I  have  lived  in  both  of  them,  I 
know  all  about  them;  one  of  them  has  always  had  a  nice  little  park,  and 
the  other  was  near  the  magnificent  old  St.  John's  park. 

The  three  lowest  wards  near  the  Battery  were  then  residences  of  the 
best  part  of  the  population  and  escaped  also,  except  Broad  street;  but  at 
26  Broad  street,  not  far  from  Wall,  three  ladies,  four  nurses  and  servants 
died  in  a  few  days,  in  a  fine  house.  A  child  also,  aged  4,  which  had  been 
in  this  house  only  one  day,  died.  The  ladies  were  "  ladies;"  the  nurses  were 
healthy  and  temperate,  but  there  was  a  small"  rain-water  drain  under  the 
basement,  and  hides  and  horns  were  stored  in  a  cellar  near  by.  Hence 
the  disease  was  malarious,  although  the  laborers  who  cleared  out  the  hides 


CHOLERA  IN  NEW  YOEK  IN  1832.  21 

were  not  attacked,  and  the  hides  were  sound  and  dry,  and  not  at  all 
offensive. 

"The  dissolute  and  intemperate  mostly  were  attacked,  viz.,  drunkards  and 
prostitutes.  Still,  very  small  irreg-ulai-ities  in  diet  were  sagely  decided  to  be  highly 
dangerous  to  the  nicest  people;  thus  everj^body  who  took  huckleberries,  or  even 
raspberries  and  milk;  were  decreed  to  be  doomed  to  death.  In  one  house  in  Madi- 
son street,  a  father  and  three  children  were  all  dead  in  twenty-four  hours  after 
eating  raspberries.  Althoug-h  the  disease  was  said  not  to  have  been  imported, 
the  low  Irish  suffered  most,  not  because  they  received  infection  from  emigrants, 
but  because  they  were  dii'ty,  intemperate,  and  crowded  together  in  the  worst  poi"- 
tions  of  the  citj^" 

If  this  were  true,  cholera  would  never  be  absent  from  our  tenement 
houses.  Cellars  and  basements  furnished  the  greater  proportion  and  worst 
form  of  the  cases:  upper  stories  were  comparatively  exempt;  hence  the 
disease  must  be  malarious.  Back  buildings  in  courtyards  were  very  sub- 
ject to  cholera:  in  one  in  Sheriff  street,  out  of  forty  inmates,  of  all 
colors  and  countries,  said  to  be  filthy  and  vicious,  23  had  diarrhoea, 
which  went  on  to  collapse  in  9,  and  to  death,  in  7;  of  which  6  were 
young  children  who  could  not  have  been  intemperate  or  very  vicious. 
Other  like  houses  produced  6,  8,  13  and  even  18  cases.  It  often  hap- 
pened that  one  crowded  house  would  show  only  two  cases  daily  until  all 
had  been  affected,  or  else  moved  away;  but  again  in  other  like  houses 
only  one  case  of  real  cholera  would  occur,  the  other  inmates  having  a 
harmless  diarrhoea  only,  although  the  house  itself  Avas  both  crowded  and 
dirty.  The  attacks  generally  came  on  in  the  night,  excited  by  the  cold, 
malarious  night  air.  Attendants  upon  the  sick  were  sometimes  attacked, 
but  the  majority  of  such  cases  Avere  either  intemperate  or  imprudent,  or 
very  susceptible  to  the  disease,  having  come  from  Brooklyn,  where  the 
pestilential  and  epidemic  constitution  of  the  air  were  not  jjrevailing,  and 
they  therefore  were  destitute  of  that  so-called  protection  Avliich  was  enjoyed 
by  those  Avho  were  acclimated  yet  dying  by  hundreds  in  the  city.  It  was 
often  observed  that  those  about  the  sick  had  diarrhoea;  but  the  signifi- 
cance of  this  in  spreading  the  disease  was  not  dreamed  of. 

But  Dr.  Atkins  might  have  guessed  better,  for  he  tells  us  ''that  cholera 
was  almost  universally  preceded  by  diarrhoea  in  Xew  York,"  Avhicli  he 
says  "  should  be  called  malignant  diarrhoea,  or  choleraic  diarrhoea;  and 
public  attention,"  he  further  says,  "  should  be  called  to  it  loudly;  for  then 
only  is  the  disease  manageable."  He  also  says  he  "cannot  leave  this  subject 
without  paying  a  tribute  to  Dr.  Kirke  of  Greenock,  Scotland,  to  Avhom  is 
due  the  praise  of  having  been  the  first  to  ascei-tain  and  publish  the 
general  fact  that  diarrhoea  is  an  almost  universal  precursor  of  true  cholera. " 
He  suppresses  the  great  fact  that  Dr.  Kirke  thought  the  diarrhoeal  dis- 
charges infective;  and  merely  says  to  the  knowledge  of  the  first  fact  Ave 
OAve  the  preservation  of  the  IIa'cs  of  thousands  in  this  city  and  throughout 
the  country.  If  he  had  proclaimed  the  second  great  truth  he  Avould  have 
saA'ed  many  more  thousands.  And  if  he  had  been  equally  frank  about 
the  known  importation  of  the  pestilence  into  Xew  York  he  would  have 
saved  tens  of  thousands.  Dr.  Atkins  sums  up  the  causes  of  Asiatic  cholera, 
thus: 

1st.  A  peculiar,  imaginary  state  of  the  atmosphere  producing  a  tendency  to 
diarrhoea.  He  says  nothing  about  the  atmosphere  from  the  discharges.  2d.  People 
are  inclined  to  sweat  in  summer  and  be  weak  and  languid,  and  may  have  cramps 
in  their  legs  if  they  tire  themselves;  this  is  a  choleraic  sweat  Avhich,  turned  in  on 


22  ASIATIC  CHOLERA. 

the  bowels,  may  cause  diarrhoea.  3cl.  The  alcoholic  diathesis  of  Dr.  I.  M.  Smith. 
4th.  Low,  damp,  malarious  situations:  civic  filtli-malaria  is  still  worse.  5th. 
Persons  with  irritable  bowels,  subject  to  diarrhoea,  are  very  liable  to  cholera, 
especially  inmates  of  almshouses  and  prisons  when  fed  only  on  mush  and  molasses 
and  soup  without  much  meat,  or  solid  food.  I  believe  that  they  are  just  as  safe 
as  in  ordinary  times,  provided  they  do  not  swallow  the  germs  or  poison  of 
cholera.  6th.  Eating  unripe,  or  even  ripe  good  fruit,  or  vegetables  usually 
deemed  digestible,  also  milk,  especiallj'  if  eaten  with  fruit.  7th.  Venereal  ex- 
cesses and  debauchery,  especially  a  midnight  spi*ee.  8th.  Anxiety  of  mind  caused 
by  fear  of  tlie  disease,  or  eating-  a  little  fruit,  from  the  sickness  or  death  of  rela- 
tives, or  woriy  about  business  in  cholera  times.  9th.  Getting  wet  in  summer 
showers,  or  by  going  to  fires,  as  firemen.  10th.  The  onlj^  really  wise  thing  he 
points  out  is  that  the  smell  of  choleraic  discharges  has  in  some  instances  been 
observed  to  produce  sudden  vomiting  and  pui'ging  in  a  healthy  person;  and  the  air 
of  houses  wliere  pei'sons  were  sick  with  malignant  cholera  has  been  known  in  about 
twenty  instances  to  produce  cholera  in  nurses;  but  these  were  mostly  ])ei'sons 
fairly  predisposed  to  the  disease  by  fatigue,  nursing,  anxietj^,  etc.  11th"  Hesa^'s, 
also  truly,  that  a  number  of  very  intei-esting  facts  have  been  stated  which  go  far 
to  prove  that  cholera  is  at  least  sometimes  infectious,  if  not  contagious.  Dr. 
King,  of  Newport,  writes  to  Dr.  Alexander  Stepiiens  that  on  July  17th,  two  ladies 
left  New  York  for  Newport,  arrived  on  the  next  day,  were  detained  in  quarantine 
for  one  week  and  then  allowed  to  leave  on  the  25th,  both  suffering-  from  malig- 
nant cholera  of  which  both  died,  one  in  the  evening  and  the  otlier  in  the  very 
niglit  on  which  they  landed;  but  the  i-ed  tape  of  a  week's  quarantine  had  been 
faithfully  observed.  On  the  30th,  Mr.  Foster  who  assisted  them  and  buried  them 
was  attacked  with  what  was  called  bilious  diarrhoea  and  colic,  from  which  he  re- 
covered and  then  relapsed  several  times  and  then  survived;  but  his  wife  and  three 
children  were  attacked  with  real  cholera,  and  the  wife  and  two  children  died. 
The  second  Foster  attacked  was  a  nursing  child  aged  18  months,  who  died  August 
4.  The  mother  died  on  the  next  day,  then  a  child  aged  3  years  was  seized  the 
same  day,  but  recovered;  and  at  noon  another  child  aged  10  years,  which  died  the 
next  day.  Then  two  hospital  nurses  wlio  attended  them,  sickened  and  died.  Tlie 
town  of  Newport  was  perfectly  healthy  and  had  no  diarrhoea  when  the  first  cases 
axTived.  The  Foster  house  was  in  good  order  and  in  a  healthy  part  of  the  toAv-n, 
so  that  there  was  no  groimd  to  suspect  special  local  causes  or  even  a  general  dis- 
temperatui'e  of  the  air. 

Dr.  EUwood  reported  to  Dr.  Atkins  that  a  man  attended  some  friends 
sick  Avitli  cholera  at  Rochester  and  then  went  to  his  home  at  Mendon, 
sixteen  miles  distant,  and  died  of  cholera  on  the  following  night;  of  six 
persons  who  attended  and  buried  him,  not  one  escaped  an  attack,  and  four 
died  within  a  week.  There  were  afterward  13  more  deaths  among  150 
people.  At  Manchester,  Ontario  county,  also  in  Oneida  county,  and  at 
Ancram,  near  Hudson,  similar  cases  were  reported,  with  from  four  to 
six  deaths  each. 

Dr.  Atkins  discusses  these  troublesome  facts  ably  from  his  point  of 
view,  viz.,  that  the  disease  is  either  atmospheric,  or  telluric;  i.e.  that 
it  must  come  either  from  the  air  or  ground.  First  he  says  it  is  of  course 
in  the  air  and  then  that  it  comes  from  the  ground;  else  it.  would  not  be 
more  common  in  low,  damp  and  filthy  places  than  on  high  and  dry  spots. 
He  again  says  it  comes  from  the  air  which  is  heavy  and  does  not  settle  on 
high  places,  but  sinks  doAvn  into  the  low  spots  where  it  becomes  perhaps 
compressed,  condensed  and  virulent.  Again  he  incorrectly  states  that 
the  disease  has  traveled  too  rapidly  to  have  been  carried  in  any  other  way 
than  by  the  air,  when  he  knew  that  it  came  not  only  in  ships  to  Quebec, 
but  also  to  Xew  York.  He  says  it  appeared  in  Quebec  first  on  June  9tli 
and  the  very  next  night  broke  out  in  several  parts  of  Montreal,  all  of 
which  we  have  seen  is  incorrect.  He  insists  that  great  stress  should  be 
laid  on  the  untruth  that  it  has  been  impossible  to  connect  the  idea  of 
importation  from  any  foreign  source  with  the  first  cases  in  Xew  York;  as 


THE  UNITED  STATES  EPIDEmC   OF  1833.  23 

these  had  been  nearly  two  mouths  in  the  city  when  no  cases  were  further 
south  than  the  frontier  of  Canada,  when  it  had  not  only  nearly  reached 
Albany  but  had  been  absolutely  let  into  Xew  York.  The  so-called  first 
case  was  reported  in  New  York  on  June  25tli,  and  was  not  the  first  case 
any  more  than  July  1st  was  the  earliest  date  in  Bellevue  Almshouse.  It 
was  acknowledged  in  Albany  on  July  3d,  but  was  preceded  by  what  is 
called  disorder  of  the  bowels. 

Xo  one  would  suppose  from  the  narrative  above  given  that  cholera  had 
actually  been  let  into  Xew  York  by  ships  in  June,  as  soon  or  almost  as 
early  as  it  was  landed  at  Quebec;  and  that  by  the  connivance  of  the 
authorities  ships  with  cholera  on  board  had  come  to  the  Staten  Island 
quarantine;  the  sick  had  been  treated  secretly  there,  and  the  Avell,  or 
apparently  well,  had  been  forwarded  to  the  city  and  up  the  Xorth  river 
to  the  west  as  rapidly  as  possible.  Most  of  then-  baggage  was  unventilated 
and  unwashed.  Of  course  the  first  cases  in  the  city  must  also  have  been 
concealed.  But  on  June  19th,  before  it  was  landed  here,  "Wm.  Shaler, 
U.  S.  Consul  to  Havana,  then  in  Xew  Y^'ork  on  leave  of  absence,  asked 
for  information  from  the  board  of  health  in  favor  of  Cuba.  He  writes 
June  19th  for  whatever  information  the  board  might  possess  about  this 
awful  visitation  of  Providence,  as  well  as  the  measures  of  precaution  which 
might  be  taken  to  prevent  its  introduction  and  propagation  in  Xew  York 
and  the  rest  of  the  country.  He  says  such  information  will  be  regarded 
as  evidence  of  kindness  by  Cuba  and  humanity,  thereby  preventing- 
loss  of  life  and  injury  to  the  immense  commercial  relations,  especially 
perhaps  the  latter.  The  medical  council  replied  to  them  July  16th,  hope- 
fully, not  having  been  informed  of  the  arrival  of  cholera  ships  at  Xew 
York,  to  the  following  questions. 

1st.  Whether  the  malignant  cholera,  as  it  noic  exists  in  the  City  of  New  York, 
can  he  prevented  by  sanitary  or  quarantine  regulations  9 

We  (the  special  medical  council)  beg-  leave  to  say  that  many  statements  have 
been  made  which  go  to  show  tiiat  the  disease  is  transmissible  "^from  one  place  to 
another  by  pei-sons  affected  with  it.  The  council  are  unwilling  to  put  forth  opin- 
ions which  would  be  at  variance  with  tlie  g-reat  weight  of  medical  authority  in 
this  direction;  at  the  same  time  it  feels  bound  to  declare  its  con\iction  that  no 
quai-antine  regulations  hitlierto  employed  and  kno^ATi  to  us  have  been,  or  we  fear 
are  likely  to  be,  effectual  in  excluding  the  malignant  cholera  from  any  pojiulous 
to'WTi  or  \aUag-e  on  this  continent. 

2d.    \Mien  it  comes,  irhat  are  the  best  means  to  mitigate  its  malignancy  ? 

The  strictest  attention  should  be  given  to  the  removal  of  all  the  common 
causes  of  disease;  all  priN-ies,  sinks,  sewers  and  stagnant  pools  of  water  should  be 
cleansed;  the  dwellings  of  the  poor  should  be  thoroughly  purified  and  white- 
washed; crowded  hovises  should  be  emptied  and  the  sick  removed  at  once  to  large 
and  airv"  hospitals.  All  pei-sons  should  be  strictly  temperate,  and  no  excess 
should  be  indulged  in.  No  fruits  or  any  other  than'simph-  farinaceous  vegetables 
can  be  eaten  with  safety.  Uneasiness  in  the  bowels,  slight  cramps  and  dizziness 
should  be  attended  to.  Looseness  of  the  bowels  should  be  treated  hy  purgatives, 
especially  calomel.     If  any  diarrhoea  is  neglected,  cholera  is  its  usual  sequel. 

3.    When  it  comes,  ichat  are  the  best  means  to  protect  life  against  its  attack? 

It  is  uuportant  to  allay  the  vomiting  and  purging,  and  if  the  patient  is  not  en- 
feebled by  previous  disease,  general  bloodletting  is  found  to  mitigate  the  spasms 
and  render  the  system  more  susceptible  to  the  action  of  the  grand  remedies, 
mercury  and  opium:  20  or  30  grains  of  calomel  with  3  grains  of  opium  and  a  large 
mustard  plaster  over  the  stomach.  Small  portions  of  ice  chewed  and  small  doses 
of  tincture  of  camphor  will  quiet  the  stomach.  The  calomel  is  to  be  repeated 
every  one,  two  or  three  hours,  till  the  stools  become  bihous;  friction,  with  rube- 
facients; dry  heat  with  bags  of  hot  sand.  If  tlie  skin  be  moist,  then  hot  powdered 
chalk  may  be  well  i-ubbed  in.  If  the  pulse  becomes  feeble  and  the  skin  cold,  rub 
in  two  pai-ts  of  strong  mercurial  ointment  with  one  part  of  camphor  and  the  same 


24  ASIATIC  CHOLERA. 

of  red  pepper.  Injections  of  hot  brandy  and  water  in  large  quantities  of  green  tea 
frequently  repeated  will  prevent  collapse. 

The  secondary  fever  must  be  treated  with  bloodletting,  piirgatives  and  small 
doses  of  nauseating  medicines.  The  dead  should  be  buried  quickly;  the  rooms 
purified  by  chlorine  gas,  and  thorough  ventilation  [although  the  latter  would  let 
in  the  generally  distempered  air];  and  the  floors  should  be  w^ashed  with  hot  lye. 
The  corpse  should  be  covered  with  cloths  soaked  in  a  solution  of  chloride  of  lime. 

The  whole  body  of  the  people  should  be  swayed  by  great  moral  principles,[such 
as  let  in  cliolera  secretly,  and  scrupulously  and  rigidly-  observe  all  the  means  of 
protecting  life.]  Beef,  mutton  or  chicken,  plainly  cooked,  eggs  shghtl3'  boiled, 
bread  made  of  wheaten  flour  only,  rice  and  mealy  potatoes,  should  form  tlie  whole 
diet.  We  fear  this  list  cannot  be  extended  without  introducing  less  wholesome 
articles.  Even  beans,  peas,  peaches,  raspberries,  puddings  containing  raisins,  are 
dangerous. 

These  directions  ruled  the  practice  of  the  whole  United  States  and 
have  not  lost  all  their  influence  to-day. 

New  York  sent  cholera  to  Newport,  K.  I.,  by  July  17th;  to  Boston  by 
July  30th;  to  Newark,  New  Jersey,  by  July  7th;  to  Philadelphia,  July  5th; 
to  Delaware,  Aug.  6th;  to  Baltimore,  Aug.  4th,  although  a  cholera  ship 
with  19  deaths  had  arrived  previously  at  the  latter  place,  of  which  no 
cognizance  was  taken  by  the  health  authorities;  to  Washington,  D.  C, 
Aug.  8th,  where  several  thousand  laborers,  mostly  emigi-ants  were  engaged 
in  street-making;  there  were  over  1,000  cases  and  more  than  500  deaths. 
It  was  sent  to  Charleston,  S.  C,  from  New  York  by  the  brig  Amelia. 

It  will  be  seen  anon  that  cholera  has  never  been  blown  by  the  winds 
from  Europe  to  any  part  of  the  coast  of  New  Jersey,  Pennsylvania,  Vir- 
ginia, North  or  South  Carolina,  Georgia  or  Florida;  nor  to  any  of  the 
West  India  Islands,  but  gets  into  the  Gulf  of  Mexico  by  means  of  ships. 
By  February,  1832,  New  York  sent  cholera  to  Havana  with  10,000  deaths  out 
of  100,000  inhabitants;  and  from  there  it  went  to  Tampico,  Campeachy 
and  Vera  Cruz,  Mexico.  At  Tampico  there  were  900  deaths  in  17  days. 
It  was  even  sent  back  again  to  New  Orleans  from  Havana.  In  1834 
cholera  was  again  sent  to  Quebec  from  Dublin  and  up  the  St.  Lawrence 
river,  and  down  to  New  York  by  August  9th,  where  it  had  already  com- 
menced July  9th,  by  its  own  importations,  which  were  again  concealed. 
But  it  cost  the  city  only  827  deaths. 

The  great  mortality  of  this  first  epidemic  is  now  attributed  to  the  then 
exclusive  use  of  surface  wells  and  out-door  privies.  Water  contamination 
was  almost  universal ;  but  the  disease  Avas  generally  ascribed  to  a  fanciful 
epidemic  constitution  of  the  air,  and  to  be  excited  by  the  most  trivial  im- 
prudences in  diet,  while  the  clothes  and  discharges  of  the  patients  were 
entirely  neglected;  and  the  movements  of  infected  persons  and  of  their 
baggage  to  and  fro  was  overlooked. ' 

Choleka  lis'  New  Orleans  in  1832. 

In  1832,  Dr.  Joseph  Jones  savs  cholera  and  yellow  fever  swelled  the 
mortality  to  8,000  out  of  55,000l  the  death  rate  reaching  the  enormous 
proportion  of  147  per  1,000  inhabitants.  It  came  down  from  Chicago  and 
St.  Louis  in  October  after  the  arrival  of  the  steamboat  Constitution  with 
cases  on  board,  many  others  having  died.  It  frequently  passed  over 
plantations  where  no  diarrhoeal  cases  arrived  to  attack  others  further  off. 
Poor  Surgeon-General  Lawson  was  in  a  wonderful  doubt  whether  it  Avas 

1  For  more  minute  information  see  United  States  report  of  the  cholei-a  of  1873, 
by  Dr.  Ely  McClellan,  U.  S.  A.,  and  Dr.  John  C.  Peters. 


CHOLERA  IN  NEW  ORLEANS  IN  1832.  25 

wafted  clown  the  Mississippi  by  the  winds,  or  came  in  the  atmosphere  of 
the  steamboat;  he  placed  no  stress  npon  the  dead  and  dying.  He  said  it 
first  attacked  the  poor  and  intemperate;  still  others  could  stalk  about 
uninjured,  but  some  could  not  peep  out  of  their  windows  without  catching 
it.  In  the  first  quarter  of  1833  there  was  only  one  death ;  then  it  was  sporadic 
till  April ;  gradually  increased  in  May,  when  it  again  became  epidemic 
and  committed  great  ravages  among  all  classes  of  citizens,  about  70  dying 
per  day.  The  Charity  hospital  was  completed  that  year  and  had  252 
cholera  patients  with  136  cures,  73  deaths  and  43  remaining.  Acute 
dysentery,  215  cases,  161  cures  and  50  deaths.  Cholera  morbus,  9  cases 
4  deaths;  malarial  dysentery,  25  cases  4  deaths;  chronic  dysentery,  61  cases 
29  deaths;  typhoid  dysentery,  8  cases  7  deaths  ;  diarrhoea,  29  cases  2 
deaths;  and  169  deaths  from  various  other  forms  of  bowel  diseases.  These 
probably  were  filth-dysentery  and  diarrhoea.  In  all  there  were  4,740 
deaths  from  cholera  in  1832,  and  it  lingered  through  1833,  with  1,000 
deaths;  and  then  there  was  no  more  until  1848. ' 


2g  ASLITIC  CHOLERA. 


CHAPTER   y. 

CHOLERA  IN  INDIA  FROM   1830   TO  1845.— IN  ASIA,  EUROPE  AND 

AMERICA  TO  1849. 

Cholera  had  almost  subsided  in  India  inl829;  in  1830  it  was  only  pres- 
ent in  Bengal  and  in  the  neighborhood  of  Bombay-  In  1831  it  was  very 
severe  near  Gaya  up  the  Ganges,  near  Benares,  and  other  places  of  pilgrim- 
age; this  was  repeated  in  1832  and  1833.  In  1834  it  spread  to  the  north- 
west provinces,  and  also  to  the  east,  far  up  the  Brahmapootra  river.  It  was 
frequent  in  Madras,  and  also  in  the  central  provinces  in  1833  and  1834. 
This  is  the  epidemic  outburst  which  it  is  supposed  was  carried  to  Mecca 
in  1835,  and  got  out  into  the  Mediterranean  sea  in  1836  and  1837,  and 
met  that  arm  of  the  pestilence  which  was  coming  from  the  west  of 
Europe. 

In  1835  cholera  almost  faded  down  in  India,  and  1836  was  another  year 
of  rest;  but  it  was  again  very  active  in  1837.  It  began  now  to  be  noticed 
that  cholera  was  apt  to  prevail  every  three  or  four  years,  and  two  theories 
about  this  were  started;  one  pointing  to  the  pilgrimages  which  increase  in 
sanctity  every  third,  sixth,  ninth  and  esjjecially  every  tAvelfth  year;  the 
other  calling  attention  to  the  effect  of  drought  and  rain.  In  very  dry 
seasons  cholera  almost  died  out,  to  spring  up  again  with  the  first  rains  and 
to  be  drowned  out  by  excessive  rainfall.  In  1838  it  was  common  in  the 
northwest  provinces,  and  in  1839  it  passed  over  the  borders  into  Cabul 
after  having  ravaged  almost  every  large  station  in  Bengal;  and  again  in 
1840.  In  1841  it  broke  out  at  Juggernaut  and  spread  over  almost  all 
India,  and  again  in  1842  and  1843.     In  1844  it  faded  down  again. 

In  1840  the  Chinese  opium  war  broke  out  and  English  troops  and 
vessels  carried  the  pestilence  to  the  Eastern  Archipelago,  where  it  had  not 
been  seen  since  1821  and  1826;  and  also  up  to  China,  Avhere  it  stayed  and 
raged  in  1841, 1842  and  1843,  and  finally  was  sent  west  through  China  and 
down  south  into  Burmah  toward  India  again;  and  also  still  further  west 
through  Central  Asia  to  Cashgar,  Yarkand,  Kokand  and  Bokhara;  and 
from  there  down  to  Cabul  and  south  into  India  through  the  northwest 
provinces.  It  also  went  down  the  river  Indus  to  Kurrachee,  where  it 
caused  that  tremendous  outbreak  in  1846  which  is  so  celebrated  in  the 
horrors  of  cholera;  causing  410  cases  and  238  deaths  in  the  86th  regi- 
ment, and  no  less  than  800  cases  in  a  few  days.  This  was  connected  with 
water  contamination.  Cholera  had  prevailed  moderately  for  some  time 
when  a  severe  rainstorm  came  on  and  washed  cholera  filth  into  the  wells. 

In  this  curious  epidemic  cholera  Avas  first  carried  far  east  to  China; 
then  forwarded  west  through  China  to  Central  Asia,  and  from  there  down 
into  the  very  heart  of  India.     This  was  "  carrying  coals  to  I^ewcastle,"  or 


CHOLERA  IN  THE  UNITED  STATES  IN   1848  AND   1849.  27 

rather  cholera  to  India,  ''with  a  vengeance."  Bnt  this  extraordinary 
epidemic  also  traveled  still  further  west;  after  coming  down  from  Bokhara 
to  Balk  and  Herat  it  turned  west  also  to  the  holy  city  of  Meshid  and  from 
there  was  carried  to  Teheran,  the  cajiital  of  Persia,  and  from  there  to  and 
between  the  Caspian  and  Black  seas,  and  again  uj)  over  its  old  route  to 
Tiflis,  Astrakhan  and  southern  Russia,  which  it  reached  in  1845  and  1846. 
In  September,  1847,  it  was  at  Moscow  and  the  great  fair  of  Xishni  Nov- 
gorod; and  soon  the  whole  of  Poland,  Moldavia,  Wallachia,  and  even 
Finland  and  Sweden,  was  under  its  influence.  From  1847  to  1849  there 
were  over  one  million  of  deaths  from  cholera  in  Russia  alone.  It  had 
broken  out  in  Berlin  as  early  as  July,  and  in  September  in  Hamburg, 
and  in  Holland;  and  a  few  cases  occurred  in  France  toward  the  end  of 
the  year  1848.  It  was  carried  from  Hamburg  to  London  on  Sept.  18, 
1848;  and  to  Edinburgh  by  Oct.  4,  also  to  Hull  and  Sunderland,  from 
Hamburg.     It  was  in  Belfast,  Ireland,  from  Edinburgh  by  Dec.  2. 

Cholera  in  the  Uxited  States  ix  1848  axd  1849. 

On  November  9,  1848,  the  ship  New  York  sailed  from  Havre  for 
New  York,  and  it  Avas  said  there  was  no  cholera  in  Havre  Avlien  she  sailed; 
and  no  one  probably  will  now  ever  know  whether  there  was  or  not.  When. 
sixteen  days  out,  cliolera  commenced  after  trunks  had  been  opened  con- 
taining clothing  of  some  who  had  died  of  cholera  in  Germany.  Before 
her  arrival  seven  of  the  steerage  passengers  had  died  and  eleven  others 
had  sickened  with  cholera  and  were  sent  ashore  at  the  Staten  Island 
quarantine.  The  next  day  the  number  of  cases  had  increased  to  20,  with  8 
deaths;  finally  there  were  63  cases  and  29  deaths;  but  the  disease  did  not 
spread  to  the  city,  although  it  Avas  known  that  numbers  had  escaped  from 
the  quarantine  and  goneoA'er  to  New  York;  Avhile  considerable  intercourse 
had  always  been  kept  up  by  visitors.  Tavo  cases  occurred  among  escaped 
emigrants  in  a  German  boarding-house;  the  rest  were  scattered  OA^er  the 
city,  and  yet  no  epidemic  folloAved  them.  The  winter  soon  set  in  quite 
severely  and  the  disease  entirely  subsided. 

On  October  31,  1848,  the  ship  SAvanton  left  Havre  also  with  a  clean 
bill  of  health,  and  Avhen  tAventy-seven  days  at  sea,  on  November  26th,  the 
first  case  of  cholera  occurred.  The  Aveather  had  become  very  warm  and 
the  passengers  opened  their  trunks  and  boxes  for  thinner  clothing;  they 
were  German  emigrants.  The  Avinds  Avhich  blew  the  ship  along  did 
not  land  cholera  in  any  part  of  Florida,  or  of  the  West  India 
Islands,  nor  in  Alabama  or  Mississippi,  nor  at  any  part  of  the  river 
below  NcAV  Orleans.  The  Swanton  arrived  December  11th,  1848,  having 
had  thirteen  deaths  and  more  than  double  that  number  of  cases  of  cholera 
at  sea.  No  quarantine  had  been  established,  and  the  usual  disputes  arose 
about  the  origin  of  the  disease  in  Ncav  Orleans,  as  cases,  supposed  to  be 
indigenous,  had  occurred  before  the  arriA'al  of  the  SAA'anton.  Then  Dr. 
Fenner  proved  that  the  Guttenberg  from  Hamburg  had  arrived  December 
6,  Avith  250  emigrants,  after  a  fifty-five  days'  passage,  with  numerous  deaths 
from  cholera.  One  of  the  earliest  cases  in  Ncav  Orleans  Avas  from  this 
vessel.  Next,  at  this  late  date,  it  Avas  found  that  the  Callao  from  Bremen 
had  ar-i'irved- on  December  8th  Avith  150  emigrants  and.  18  deaths  from 
cholera.  This  epidemic  cost  Ncav  Orleans  2,500  deaths.  On  Dec.  20  the 
steamboat  Convoy  brought  the  disease  from  Ncav  Orleans  up  the  Missis- 
sippi river  to  Memphis.     Dec.  27  tiie  Amaranth  brought  it  to  St.  Louis, 


28  ASIATIC  CHOLERA. 

followed  by  others.  Dec.  22  the  Peytona,  and  Dec.  24  the  Savannah, 
brought  it  back  to  Xew  Orleans  and  established  another  but  mild  epidemic. 
Dec.  25  it  was  brought  by  steamboat  from  New  Orleans  to  Cincinnati. 
Thus  the  pestilence  Avas  carried  up  the  Mississippi,  Missouri  and  Ohio  rivers 
and  even  reached  Chicago,  Buffalo,  Detroit  and  Niagara  Falls  before  it 
was  brought  west  from  Canada  or  New  York.  The  emigration  was  very 
great  in  1849,  as  gold  had  just  been  discovered  in  California.  As 
the  principal  starting-place  for  over  the  plains  Avas  St.  Louis,  that  city 
suffered  more  heavily  than  any  other  place.  It  was  carried  thence  across 
the  country  to  Sacramento  and  San  Francisco.  The  Indians  also  suffered 
very  heavily,  as  Avell  as  the  emigrant  trains  and  United  States  troops. 

In  the  meantime  several  other  cholera  ships  had  arrived  at  New  York, 
but  the  disease  did  not  declare  itself  in  the  city  until  May  11,  1849,  Avhen 
it  commenced  in  a  lodging-house  in  Orange  street  and  was  followed  by 
5,017  deaths.  In  the  interval  the  whole  West  was  overrun  with  cholera 
from  New  Orleans.  Among  others  it  was  carried  up  the  Mississippi  and 
Ohio  rivers  to  the  Cumberland  and  doAvn  south  along  that  river  to  Nashville, 
Tennessee,  by  the  Caroline  AVatkins  and  other  steamboats.  In  almost  all 
these  places  the  disease  was  declared  to  be  malarial  and  of  local  origin. 
Dr.  James  Wynne  Avas  the  principal  disseminator  of  this  plausible  but 
erroneous  doctrine,  and  Avas  ably  seconded  by  Dr.  Bell  of  Louisville.  Some 
of  their  notions  of  the  spontaneous  origin  and  purely  malarial  foundation 
of  cholera  are  very  curious  indeed.  For  instance,  the  outbreak  in  the 
Baltimore  Almshouse  in  July,  1849.  Although  Dr.  Nathan  R.  Smith 
proved  that  a  poor  English  emigrant  had  called  at  his  office  in  Baltimore 
on  July  5th  and  had  been  removed  to  the  Almshouse,  Avhere  he  died  on 
the  7th,  yet  Dr.  Wynne  persisted  that  the  disease  Avas  not  imported.  The 
Avhole  house,  800  feet  long,  and  the  grounds,  seemed  in  splendid  condition 
and  had  nearly  700  inmates.  But  just  outside  of  the  north  wall  there  Avas 
a  large  filthy  pool,  the  contents  of  which  Avere  in  a  state  of  actual  fermen- 
tation from  the  drainage  into  it  of  a  large  pig-sty,  the  Avashings  from  the 
dead-house,  an  overfloAving  priA'y,  and  from  the  Avash-house  Avhere  all  the 
soiled  linen  Avas  Avashed.  This  was  called  pure  fever-and-ague  malaria. 
Of  the  inmates  53  Avere  discharged,  62  escaped  and  of  the  rest  99  died 
of  cholera.  Those  on  the  basement  floor  nearest  this  mixed  civic  filth, 
called  simple  malaria,  suffered  most,  and  in  one  Avard  all  died.  Those  in 
the  upper  stories  and  on  the  sides  furthest  removed  from  the  filth  suffered 
least;  but  some  Avho  Avere  much  in  the  3^ard  died  in  the  attic  AAdiere  they 
slept.  The  germs  Avere  imported  into  the  house,  and  the  immense  amount 
of  festering  filth  multiplied  the  disease.  The  hospital  part  of  the  building 
was  unAvisely  placed  nearest  the  filth,  and  the  mortality  was  necessarily 
great.  Disinfection  AA'as  unknoAvn,  and  the  discharges  were  throAvn  into 
overfioAving  privies.  This  is  the  pi\'otai  case  of  all  the  doctrines  about  the 
so-called  pure  malarial  origin  of  cholera  in  the  United  States;  and  hoAV 
slender  the  basis  of  it  is,  is  evident. 

One  of  the  most  curious  cases  of  infection  was  that  of  Buffalo,  to  Avhich 
it  was  brought  by  steamboat  from  Chicago  up  Lake  Michigan  and  doAvn 
Lakes  Huron  and  St.  Clair.  It  arrived  in  Buffalo  May  13,  1849,  whereas 
it  did  not  commence  in  Ncav  York  till  May  11th.  The  Chicago  cases 
came  from  St.  Louis  and  Ncav  Orleans.  Another  case  Avas  sent  to  Buffalo 
from  Cincinnati  via  Sandusky,  June  1st,  and  on  June  4th  another  AA'as 
brought  by  steamboat  from  Chicago.  Buffalo  had  858  deaths  in  this 
epidemic  up  to  Sept.  7,  1849. 


CHOLERA  IN  THE  UNITED  STATES  IN  1848  AND   1849.  29 

The  pestilence  was  not  only  carried  north  from  New  Orleans  but  also 
south  to  plantations  in  Louisiana,  in  the  majority  of  Avhich  cases  the  con- 
veyance of  the  infection  could  be  distinctly  traced.  In  January,  1849,  it  was 
carried  to  Mobile,  with  only  149  deaths,  as  that  city  generally  escapes  lightly, 
owing,  it  is  said,  to  the  pure  drinking  water  with  which  the  city  is  supplied. 

It  was  also  taken  to  Texas  from  New  Orleans  by  the  8th  United  States 
Infantry.  General  Worth  died  of  it  at  San  Antonio  on  j\Iay  7.  It  Avas 
diffused  through  Texas  by  the  movements  of  troo})s  and  emigrants  and 
carried  into  Mexico  by  refugees  from  Texas.  The  Mexicans  had  a  lively 
recollection  of  the  cholera  of  1833,  and  most  of  them  fled. 

The  emigration  to  the  gold  fields  was  so  great  that  New  Orleans  was 
fed  with  constant  arrivals  from  Europe,  and  again  sent  cholera  up  the  Mis- 
sissippi and  beyond  in  1850  and  1851.  Eight  or  ten  cholera-laden  steam- 
boats arrived  at  St.  Louis  and  aroused  the  disease  afresh,  and  seventeen 
of  her  physicians  died.  On  April  2Uth  the  Illinois  and  Michigan  canal 
was  opened  to  Chicago,  and  on  the  39th  the  John  Drew  arrived  from  St. 
Louis  with  passengers  and  emigrants  directly  from  New  Orleans,  followed 
by  314  deaths.  On  April  21st  the  Sacramento  arrived  at  St.  Joseph, 
Missouri,  with  a  large  number  of  California  emigrants,  and  then  the  Mary 
with  over  50  deaths.  These  emigrants  carried  the  disease  over  the  river 
Platte  route  and  finally  brought  it  to  Sacramento,  in  October,  1850,  at 
almost  the  same  time  that  it  reached  San  Francisco  by  the  steamship 
Caroline,  from  Panama,  to  which  it  had  been  brought  also  by  steamships 
from  New  York.  The  Platte  Indians  contracted  the  disease,  and  com- 
mitted daily  murders  on  the  unoffending  whites  whom  they  supposed  had 
secretly  poisoned  them.  By  July,  1849,  it  commenced  to  arrive  at  Buffalo, 
Chicago,  and  the  west  from  New  York. 

Louisville,  Kentucky,  as  usual,  escaped  with  slight  outbreaks;  for  it 
seems,  like  Lyons  in  France  and  Wurtzbiirg  in  Germany  and  Mobile  in  this 
country,  a  city  of  refuge  from  the  disease,  although  it  occasionally  has 
severe,  but  circumscribed  outbreaks.  In  July,  August  and  September, 
1849,  there  were  only  five  deaths  in  New  Orleans,  but  on  Oct.  15  the 
Cromwell  from  Havre  arrived  with  204  steerage  passengers,  of  Avhich  twelve 
had  died  of  cholera.  She  was  ordered  to  the  opposite  side  of  the  river 
and  her  passengers  were  forwarded  to  St.  Louis  the  next  day.  On  Oct. 
15  the  steamboat  General  Lane  and  others  brought  it  down  the  river. 
Oct.  23  the  Berlin  from  Liverpool  arrived  with  206  Scotch  and  English 
emigrants,  with  40  deaths,  and  her  passengers  Avere  also  at  once  sent  up 
.the  river.  Of  course  during  November  cholera  prevailed  to  an  alarming 
extent,  and  on  the  2Gth  the  Gypsy  from  Liverpool,  where  the  disease 
prcA'ailed,  arrived  with  322  emigrants  and  19  deaths.  On  the  27th  came  the 
Fingal,  with  322  passengers  and  37  deaths.  Hence  the  disease  lasted  over 
till  1 850  in  New  Orleans.  Then  the  Falcon  arrived  from  Panama,  Chagres 
and  Havana  with  25  deaths,  the  disease  being  epidemic  in  all  these  places. 
The  pestilence  did  not  extend  east  of  the  Alleghany  mountains.  Prior  to 
May,  1850,  St.  Louis  had  953  deaths;  Cincinnati  had  1,400;  Sandusky 
lost  18  per  cent  of  her  population.  Whole  parties  of  miners  and  emigrants 
were  decimated  on  the  great  western  plains. 

From  New  Orleans  it  Avas  also  carried  back  to  Cuba  and  the  Isthmus 
of  Panama.  And  thus  the  pestilence  Avent  to  and  fro  as  travel  predomi- 
nated. No  East,  West,  North  or  South  Avas  exempt  from  it.  San  Francisco 
only  lost  250;  Sacramento  suffered  far  more  heavily,  for  out  of  8,090  in- 
habitants, 4,000  fled,  and  of  the  remainder  1,000  died. 


30  ASIATIC  CHOLERA. 

In  18-48  there  were  no  less  than  1,61G  deaths  from  cholera  in  New 
Orleans;  in  18-49,  3,176:  in  1850,  1,448;  in  1851,  430;  in  1852,  1,320; 
in  1853,  585;  none  in  1854;  883  in  1855;  43  in  1856;  24  in  1857;  26  in 
1858;  27  in  1859;  30  in  1860;  12  in  1861;  none  in  1862;  4  in  1863;  5  in 
1864;  9  in  1865;  1,294  in  1866. 

Cholera  ix  St.  Louis,  Missouri,  1848-1853. 

This  city  was  the  most  interesting  and  important  receiving  and  dis- 
tributing point  of  cholera  in  1849  and  the  subsequent  years.  Its  full 
history  has  been  written  only  quite  lately  by  Dr.  Robert  Moore,  C.  E.  We 
have  seen  that  cholera  was  brought  to  Xew  Orleans  early  and  late  in 
December,  1848.  During  the  last  week  of  this  month  several  steamboats 
came  to  St.  Louis  from  Xew  Orleans  with  the  disease  on  board.  The  first 
was  the  Amaranth,  Dec.  28th,  with  30  cases.  On  Jan.  2,  1849,  the  steam- 
boats Aleck,  with  36  cases,  the  Scott  and  St.  Paul  with  26  cases,  arrived; 
on  Jan.  7th  the  Gen.  Jessup  with  many  cases  and  six  deaths.  All  these 
boats  brought  many  infected  emigrants,  who  Avith  all  their  infected  bag- 
gage were  landed  and  scattered  through  the  city  without  the  slightest 
delay  or  hinderance;  hence  on  the  9th  several  cases  were  reported,  which 
were  said  to  be  sporadic,  and  caused  by  cabbage.  The  pestilence  Avas  now 
fairly  planted,  and  for  the  next  four  years  was  never  wholly  absent  from 
St.  Louis.  In  Jan.  1849,  there  were  36  deaths;  in  February  only  21;  in 
March,  78;  in  April,  126.  On  April  12  the  steamboat  Iowa  came  from  Xew 
Orleans  with  451  Mormon  deck  passengers,  and  9  deaths  from  cholera, 
and  in  the  first  week  in  May  there  were  78  deaths.  St.  Louis  now  became 
alarmed  and  used  chloride  of  lime  in  the  back  yards  and  dirty  places.  On 
May  9th  there  were  24  new  cases,  and  the  steamboat  America  arrived  with 
22  deaths  on  board,  and  by  3Iay  14th  there  were  26  deaths  in  St.  Louis 
per  day.  On  the  night  of  May  17th  the  gi'eat  fire  occurred  which  burnt 
26  steamboats  and  many  blocks  of  buildings,  but  the  pestilence  was  only 
slightly  checked  thereby,  there  being  20  deaths  a  day  for  several  weeks 
after,  but  on  June  9th  there  Avere  37,  and  in  the  week  ending  June  17th, 
402  deaths,  or  57  per  day.  On  June  17  the  Sultana  came  with  nearly  400 
more  immigrants,  25  deaths,  and  6  bodies  on  board.  For  the  week  ending 
June  24  there  were  601  deaths,  or  86  per  day.  On  the  25th  a  mass  meet- 
ing Avas  held,  and  the  mayor,  common  council  and  health  officers  deposed, 
and  AA^ard  committees  of  public  health  apjDointed  Avith  absolute  poAvers. 
Block  inspectors  Avere  selected  for  each  block  of  houses,  and  some  of  the 
best  and  Avealthiest  citizens  served  upon  them  Avithout  pay.  All  disobedi- 
ence of  orders  was  punished  by  fines  of  8500  or  less  and  imprisonment. 
School-houses  were  seized  for  hospitals,  and  district  j^hysicians  appointed. 
The  city  Avas  thoroughly  cleansed  and  the  streets  and  yards  by  the  block 
inspectors.  Coal,  sulphur  and  tar  were  burnt  in  every  street,  and  a  day 
of  fasting  and  prayer  ordained.  But  the  committee  of  safety  continued 
to  work  Avithout  regard  to  the  day  of  fasting,  and  determined  to  fast  from 
cholera  and  not  from  food  or  work,  and  took  that  day  to  establish  a  quar- 
antine and  stop  all  infected  boats,  which  the}'  did;  and  also  kept  the  fires 
going  and  the  sulphur  and  tar  smoke,  A\diich  filled  the  Avhole  city.  In 
spite  of  all  this,  on  July  10th  the  deaths  reached  184,  but  then  the  pesti- 
lence rapidly  declined,  and  on  July  31st  there  were  only  three  deaths  from 
cholera.  The  committee  had  only  spent  $16,000  out  of  an  appropriation 
of  150,000,  so  generous  and  earnest  were  the  citizens.  The  total  mortality 
was  4,555. 


CHOLEEA  IN  ST.  LOUIS,  1848-1853.  3^ 

St.  Louis  depended  entirely  upon  surface  wells  for  drinking  water,  and 
had  numberless  outdoor  privy  pits,  which  contaminated  them.  If  tar  or 
carbolic  acid  could  have  been  thrown  into  the  worst  wells,  and  the  privies 
could  have  been  thoroughly  disinfected  Avith  sulphuric  acid,  the  epidemic 
would  have  soon  been  over.  Burning  tar,  sulphur  and  coal  to  purify  the 
air,  when  the  disease  was  in  the  wells  and  privies,  would  be  amusing  at  the 
present  day,  if  it  had  not  been  done  lately  in  Toulon  and  Marseilles. 

During  the  next  year,  1850,  there  were  deaths  from  cholera  in  every 
month,  the  total  being  883,  of  which  458  occurred  in  July.  In  1851, 
there  were  845  deaths,  of  which  505  happened  in  June.  February, 
October  and  December  were  the  only  months  exempt.  In  1852  there  were 
deaths  again  in  every  month;  the  total  for  the  year  being  802.  During 
these  four  years  no  less  than  6,847  persons  had  died  of  cholera  in  St. 
Louis. 

In  1853  the  pestilence  was  wholly  absent  for  the  first  time  since  1848; 
but  in  1854  it  appeared  again  with  renewed  vigor,  and  killed  1,534  per- 
sons.    Then  it  died  out  till  1866. 

The  great  dispute  has  always  been  how  the  cholera  came  from  Havre 
in  1848  to  Xew  York  and  Xew  Orleans,  while  Havre  gave  clean  bills  of 
health.  It  was  common  then  for  German  emigi-ants  to  go  from  Hamburg 
and  Bremen  to  Ha^Te  to  ship  for  the  United  States,  and  it  is  possible  that 
there  was  no  cholera  at  Havre  except  among  them,  which  Avas  not  counted. 
It  broke  out  in  Paris  in  March,  1849,  which  is  about  the  time  it  takes  to 
come  from  Havre.  It  always  prevails  slightly  for  several  weeks  or  months 
until  the  cases  can  no  longer  be  concealed  from  their  numbers.  By  the 
end  of  June,  1849,  Paris  had  had  33,274  cases  and  15,667  deaths,  when 
it  gi'adually  declined  and  ceased  altogether  in  October.  It  reached  Mar- 
seilles from  Paris  in  August,  and  soon  after  Toulon,  from  whence  it  Avas 
carried  east  to  Xice,  Genoa,  Leghorn  and  Naples,  just  as  it  had  been  in 
1834.  It  killed  53,293  persons  in  England  in  1849;  and  out  of  119 
places,  in  no  less  than  73  it  was  distinctly  traced  to  new  arrivals.  In  others 
it  was  impossible  to  trace  its  importation,  as  all  the  diarrhoeal  cases  were 
overlooked,  and  soiled  clothing  was  not  thought  of. 


32  ASIATIC  CHOLERA. 


.CHAPTER  VI. 

CHOLERA  IN  INDIA,  ASIA,  EUROPE,  AND   THE  UNITED   STATES, 
FROM  1848  TO  1854. 

While  cholera  was  progressing  and  staying  in  Europe  and  the  United 
States  it  was  again  coming  np  from  India.  In  1847  Hindostan  was  com- 
paratively free.  In  1848  there  was  a  great  deal,  especially  at  Juggernaut. 
In  1849  it  had  progressed  to  the  northwest  provinces,  and  also  over  to 
Bombay,  although  rain  fell  at  the  rate  of  If  inches  a  day  and  a  southwest 
monsoon  was  blowing  at  an  average  pressure  of  3 A  to  5  lbs.  per  square  foot 
and  pushing  along  at  the  rate  of  twenty-five  miles  an  hour  against  the 
advancing  cholera. 

It  was  very  prevalent  in  1850.  Thus  there  were  only  69  deaths  in 
Bombay  in  1848;  2,269  in  1849,  4,729  in  1850;  4,020  in  1851;  1,555  in 
1852,  and  1,339  in  1853.  In  1851  it  got  out  from  Bombay  into  the  Persian 
Gulf,  arrived  at  Bassorah  June  10th,  committing  great  ravages,  and  went 
up  the  river  Tigris  to  Bagdad  by  Sept.  18th,  killing  1,847  persons  in 
fifty  days  and  then  disappearing  Nov.  17.  This  epidemic  was  connected 
with  the  great  Persian  pilgrimages  to  Kerbela,  and  Meschid  Hossein  and 
Meschid  Ali,  just  below  Bagdad. 

From  W.  A.  Shephard's  book,  "  From  Bombay  to  Bassorah,"  we  learn 
that  the  latter  city  has  many  pilgrim  boats  which  are  always  crowded  with 
the  living  and  dead,  going  up  to  Kerbela  and  the  two  jVIeschids.  The 
living  cargoes  of  men,  women  and  children  are  huddled  together  like  pigs, 
from  100  to  150  being  crowded  into  a  space  of  40  feet  by  20,  with  25  or  more 
dead  bodies  piled  about,  which  is  rather  close  packing  in  the  warm  months. 
As  these  pilgrim  boats  went  to  windward,  the  scent  was  anything  but  pleas- 
ant, and  it  was  difficult  to  say  whether  the  living  or  dead  were  most  dis- 
agreeably fragrant.  Then  the  Arabs,  living  along  the  shores,  not  only 
stop  the  boats  and  rob  the  living,  but  also  seize  the  dead  bodies  and  hold 
them  in  pawn  until  the  ransom  set  upon  them  is  paid  by  the  sorrowing 
relatives,  who  believe  that  the  souls  of  their  defunct  friends  Avill  never 
reach  Paradise  unless  their  bodies  are  buried  at  the  tomb  of  Hossein  and 
Ali,  or  at  Kerbela. 

Dr.  Boutolette  says,  in  1849  to  1850  there  passed  near  Kerbela  no  less 
than  52,053  pilgrims  with  64,138  beasts  of  burden,  4,504  muleteers  and 
2,837  loads  of  human  corpses,  which  with  three  to  a  load  made  no  less 
than  5,674  dead  human  bodies  going  to  Kerbela,  or  Nedjed,  near  Bagdad. 

From  Bagdad  cholera  passed  up  the  old  route  to  Tabreez,  killing  12,000 
people,  and  up  between  the  Black  and  Caspian  seas  to  southern  Russia, 
and  from  thence  to  northern  Europe,  Denmark,  Norway,  and  in  1853  to 
numerous  towns  in  north  Prussia  and  Holland,  and  soon  was  in  London 
and  Newcastle. 


CHOLERA  FROM   1848  TO   1854.  33 

In  short,  in  1851, 1852  and  1853,  cholera  again  was  Drought  to  Europe,, 
especially  Russia,  Germany,  Holland,  Belgium,  France,  Sweden,  Norway,. 
England,  etc.  From  July  to  December,  1853,  London  had  1,265  cases; 
Liverpool  and  Manchester  were  severely  attacked;  Copenhagen  had  7,200 
cases;  France  had  125,725  deaths  in  fourteen  months.  Spain  and  Italy 
were  also  involved;  Genoa  had  5,318  cases;  Sardinia  45,000,  Naples  12,- 
600,  Messina  20,000.  Munich  had  a  long  epidemic  lasting  from  July 
through  the  whole  winter  to  the  next  April,  with  4,800  cases. 

It  is  also  a  matter  of  doubt  if  the  United  States  was  entirely  free  from 
1848  to  1854.  Chicago  had  630  deaths  in  1852.  It  also  persisted  in  St. 
Louis  and  various  other  places.  Early  in  1854  no  less  than  28  infected 
vessels  sailed  for  the  L'"nited  States  from  England,  Holland,  France,  Ham- 
burg and  Bremen  with  1,141  deaths  on  their  voyages;  but  it  was  not  in 
New  York,  or  even  at  the  Staten  Island  quarantine  that  the  disease  first 
showed  itself.  The  initial  New  York  case  dates  June  14th,  1854.  It  is 
well  known  that  cholera  ships  arrived  in  New  Orleans  in  the  last  months 
of  1853  and  early  in  1854;  but  no  epidemic  arose  till  May,  when  200  died 
in  one  week.  It  remained  until  its  records  were  lost  in  those  of  the  yellow 
fever  of  that  year.  It  was  at  Memphis,  from  New  Orleans,  by  June  3d, 
at  Nashville,  June  20.  But  long  before  this,  it  had  been  sent  up  from 
New  Orleans  directly  to  St.  Louis.  In  December,  1853,  there  were  a  few 
cases.  But  in  January  and  February,  1854,  when  crowds  of  emigrants 
began  to  pour  into  the  city,  the  epidemic  commenced  and  persisted  dur- 
ing the  year,  being  most  severe  in  April  and  June,  and  St.  Louis  again 
suffered  more  heavily  than  any  city  in  the  United  States,  losing  3,547 
cases.  The  emigrants  from  New  Orleans  were  again  loaded  at  once  on 
river  steamboats  without  stopping  in  the  city,  and  thus  the  pestilence  went 
up  to  the  head  waters  of  the  Mississippi,  Missouri  and  Ohio  rivers.  In 
April  it  commenced  in  Chicago  and  lasted  through  November,  with  1,404 
deaths.  On  May  19th  it  was  at  Detroit,  either  from  St.  Louis,  Chicago 
or  New  York,  or  all  three.  In  June  it  was  at  Ann  Arbor,  Michigan, 
with  two  cases  from  Chicago  and  two  from  New  York. 

Dr.  Alonzo  Clark  puts  more  blame  than  this  upon  New  York,  and  per- 
haps justly.  Cholera  ships  arrived  there  in  November,  and  forwarded 
almost  all  their  passengers  west,  and  he  thinks  they  carried  the  disease  in 
their  baggage.  On  May  16th  the  North  America  came  from  Liverpool 
with  768  passengers  and  17  deaths;  and  120  more  were  attacked  at  the 
Staten  Island  quarantine  with  70  deaths.  Then  came  the  Progress,  from 
Liverpool,  May  18,  with  715  passengers  and  44  deaths.  Next  the  Charles 
Crocker  with  414  emigrants,  June  3d,  and  36  deaths. 

As  before  stated,  the  first  death  reported  in  1854  in  New  York  city  was 
Jvine  14th,  and  as  early  as  June  2  it  was  at  Buffalo,  most  probably  from 
New  Orleans  and  St.  Louis.  July  18  it  was  at  the  Suspension  Bridge, 
Niagara  Falls.  By  June  17  it  was  sent  from  New  York  to  Philadelphia. 
Canada  also  competed  with  New  York  aiul  New  Orleans.  The  Glenmanna 
came  to  Quebec,  from  Liverpool,  June  15,  after  having  thrown  forty-five 
dead  of  cholera  overboard.     It  soon  became  epidemic. 

The  Niagara  Falls  outbreak  is  very  interesting.  The  disease  was  at 
Buffalo  and  Detroit,  west  of  Niagara,  first;  whether  from  New  Orleans  and 
St.  Louis  or  from  New  York  or  Canada  no  one  knows.  From  Buffalo 
it  was  sent  to  Niagara  Falls,  where  the  Suspension  Bridge  was  being  built 
and  many  laborers  were  encamped  on  low  marshy  ground,  with  the  usual 
carelessness  about  privy  pits  and  still  more  recklessness  about  water  sup- 
3 


34  ASIATIC  CHOLERA. 

ply.  A  so-called  sulpliur  spring  was  discovered,  and  the  great  bridge 
builder,  Mr.  Eoebling,  had  a  marble  basin  made  for  it.  When  the  bridge 
was  finished,  the  laborers  gone  away,  and  the  open  privy  pits  abandoned, 
the  so-called  sulphur  water  ceased  to  flow,  and  only  ordinary,  not  very 
sulphurous,  spring  or  loAV-ground  water  is  now  to  be  found,  although  the 
monumental  stone  basin  is  still  in  place.  An  inscription  to  cholera  might 
now  well  be  put  upon  it,  as  the  outbreak  at  Niagara  was  tremendous. 

In  1854  cholera  was  also  carried  east  from  France,  especially  Marseilles 
and  Toulon,  to  the  Crimea,  where  it  affected  the  Turkish,  English  and 
French  armies,  and  was  carried  down  through  Asia  Minor  toward  Persia 
and  India, 


THE  EPIDEMIC  OF  1866.  35 


CHAPTER  VII. 

THE  EPIDEMIC  WHICH  REACHED  THE  UNITED  STATES  IN  1866. 

All  the  previous  outbreaks  in  Europe  had  commenced  in  southern  Eus- 
sia,  traveling  up  from  Persia  and  Asia  Minor,  then  swept  westward 
toward  Germany,  been  brought  from  thence  to  England,  Ireland  and 
Erance,  and  from  thence  forwarded  to  the  United  States. 

In  18 G5.  for  the  first  time  in  many  years,  the  great  twelve-year  festi- 
vals in  Ilindostan  preceded  the  Mecca  pilgrimages,  which  vary  by  twenty- 
nine  days  each  year,  as  the  Mohammedan  is  a  short  year  of  twelve  lunar 
months  of  twenty-eight  days  each,  or  336  days  in  all.  There  Avas  a  great 
prevalence  of  cholera  in  the  Bombay  Presidency  with  84,000  deaths,  com- 
mencing as  early  as  March,  1865,  and  from  there  it  was  carried  over  to 
Mecca  in  April  and  May,  when  30,000  pilgrims  died.  By  May  23  it  was 
at  Suez,  brought  by  steamships,  which  now  carry  many  pilgrims,  and 
forwarded  to  Alexandria  by  railroad  on  June  1st.  It  reached  Mar- 
seilles on  June  11th  by  steamships  carrying  Algerine  pilgrims,  and  from 
thence  up  to  Paris,  with  a  few  deaths  in  July,  August  and  September,  but 
with  4,466  in  October,  1,218  in  November,  and  768  in  December.  From 
Paris  it  soon  reached  Havre,  which  concealed  its  epidemic,  and  on  October 
12th  gave  the  Atalanta,  with  604  passengers,  a  clean  bill  of  health;  but 
she  had  102  cases  and  23  deaths  before  she  reached  New  York.  The  Her- 
mann arrived  with  seven  deaths  on  November  16.  Up  to  Dec.  30,  1865, 
thirty-six  vessels  from  cholera  ports  arrived  at  New  York,  and  by  Novem- 
ber 22  it  broke  out  in  the  emigrant  hospital  on  Ward's  Island;  but  owing 
to  the  coldness  of  the  Aveather  the  pestilence  did  not  extend. 

According  to  Dr.  Ely  McClellan,  the  outbreak  in  North  America  com- 
menced with  the  steamship  England  from  Liverpool,  March  28,  1866, 
with  1,185  emigrants,  160  cases,  and  46  deaths  before  she  reached  Halifax. 
Then  followed  the  Virginia  from  Liverpool,  arriving  at  New  York,  April 
18,  1866,  with  1,029  steerage  passengers,  38  deaths,  and  46  sick  on  arrival. 
Erom  that  time  to  Nov.  28,  cholera  ships  arrived  at  New  York,  with 
8,491  passengers  and  crew,  and  172  deaths,  or  10  per  cent,  from  cholera;  six 
of  the  vessels  were  from  Liverpool,  five  from  Hamburg,  one  from  Bremen, 
one  from  Antwerp,  two  from  London,  and  two  from  Havre;  all  of  which 
places  were  more  or  less  infected.  On  the  Liverpool  ships  there  had  been 
492  deaths;  on  the  Hamburg  96;  on  the  Havre  113;  on  the  Bremen  12; 
on  the  Antwerp  18;  on  the  London  1. 

Erance  had  so  often  received  the  cholera  from  Germany  that  she  returned 
the  compliment  for  once  this  year  and  infected  Holland,  Belgium,  Ham- 
burg and  Bremen.  Many  of  the  Liverpool  steamships  touched  at  Havre, 
and  filled  up  with  infected  persons  and  clothes.     Besides,  cholera  had  been 


3G  ASIATIC  CHOLERA. 

landed  at  Southampton,  England,  as  early  as  June,  July,  August  and 
September,  18G5,  by  steamships  from  Alexandria  and  Egypt. 

The  first  death  in  Xew  York  city  in  1866  was  May  ^,  at  a  tenement 
house  far  up  town  in  93d  street,  near  Third  avenue,  possibly  brought  over 
from  Ward's  Island;  the  second  on  the  same  day  in  Mulberry  street;  the 
third  at  303  Broome  street,  near  Forsyth;  the  fourth  washed  the  soiled 
clothing  of  the  third;  the  fifth  was  in  a  tenement  house  in  West  20th 
street;  the  sixth  in  Hester  street;  the  seventh  near  Pitt  and  Willett  streets; 
the  eighth  on  Cherry  street;  the  ninth  near  Greenwich  and  Liberty  streets. 
Xo  connection  could  be  traced  by  the  late  Dr.  Elisha  Harris  between  these 
cases,  except  the  third  and  fourth;  but  2,094  persons  from  infected  ships 
had  already  been  let  loose  in  the  city.  None  of  the  first  deaths  were  emi- 
grants; no  account  had  been  or  could  be  kept  of  the  non-fatal  cases.  The 
seeds  of  the  disease  had  been  soAvn  b}^  the  soiled  clothing  of  the  emi- 
grants, or  by  the  diarrhoeal  discharges  of  those  who  recovered.  These 
are  the  only  solutions  of  this  curious  problem.  The  germs  of  the  disease 
had  been  undoubtedly  imported,  and  affected  disposed  or  susceptible  per- 
sons in  the  seemingly  mysterious  way  that  cholera  always  attacks  large 
cities.  Up  to  July  8  there  were  only  21  deaths  from  cholera  in  New  York, 
none  of  the  victims  of  which  were  emigrants,  but  merely  persons  who 
resided  in  localities  frequented  by  freslily  landed  emigrants.  The  first 
case  in  Brookh^n  Avas  in  the  first  week  of  July  in  a  quarter  entirely  inhabi- 
ted by  foreigners,  and  established  an  intense  local  epidemic. 

July  11  it  became  epidemic  again  in  the  emigrant  hospital  on  Ward's 
Island.  July  3  the  first  fatal  case  happened  among  the  garrison  of  Fort 
Columbus,  on  Governor's  Island,  the  then  general  recruiting  dejDot  of  the 
United  States  army,  and  from  this  last  center  the  disease  was  extensively 
diffused  over  the  whole  country.  The  first  case  was  a  recruit  who  came 
from  Minneapolis,  Minnesota,  1,000  miles  and  more  away,  who  spent  three 
days  in  New  York  before  going  to  Governor's  Island.  From  Governor's 
Island  it  was  sent  by  troops  to  Hart's  Island  in  Long  Island  sound;  to  T^^bee 
Island,  Georgia;  to  Louisiana  by  way  of  New  Orleans;  to  Texas  via  Gal- 
veston; to  Louisville,  Kentucky,  overland;  to  Eichmond,  Virginia;  to 
Nicaragua  bay;  to  Norfolk,  Va. ;  to  Bowling  Green,  Kentucky.  The  next 
principal  army  center  of  cholera  was  NcAvport  Barracks,  Kentucky,  probably 
derived  from  Cincinnati;  and  from  there  it  Avas  sent  to  Augusta  and 
Atlanta,  Georgia,  and  to  Nashville  and  Memphis,  Tennessee.  If  cholera 
can  cling  so  long  to,  travel  so  far  with,  and  ravage  so  extensively  such  a 
fine  body  of  troops  as  compose  the  United  States  army,  when  cared  for 
by  such  capable  army  surgeons,  what  are  the  chances  of  the  convej^ance 
of  the  disease  by  large  bodies  of  dirty  emigrants  with  little  medical  attend- 
ance at  sea  and  not  much  more  on  land  ? 

As  New  York  must  bear  the  brunt  and  odium  of  having  introduced 
cholera  into  the  United  States  in  1866,  and  as  that  epidemic  Avas  par- 
ticularly well  studied  by  my  late  lamented  friend,  Dr.  Elisha  Harris,  Avhile 
it  offered  all  the  iiroblems,  solved  and  unsolved,  Avhich  may  and  must 
puzzle  doctors  and  sanitarians  in  small  as  well  as  in  large  toAvns  and  cities, 
I  will  devote  fair  space  to  it.  The  equally  lamented  sanitary  superin- 
tendant.  Dr.  EdAvard  R.  Dalton,  took  control  of  every  house  Avhicli  cholera 
entered.  A  daily  marked  map  of  every  case  of  severe  diarrhoea  and  chole- 
raic disease  was  kept;  over  50  telegraph  stations  were  connected  with  the 
health  office,  and  2,000  policemen  in  addition  to  the  sanitary  corps  aided 
in  giving  the  earliest  information  of  every  suspicious  and  dangerous  case. 


CHOLEKA  IN  NEW  YORK  IN  1866.  Q- 

O  ( 

Distribution  of  the  First  25   Fatal   Cases  of  Cholera  ix   Xev.' 

York  City  ix  1866. 

Dr.  Elislia  Harris  says: 

"  Previous  to  July  8th,  31  cases  of  well-marked  cholera  had  terminated  fatally. 
They  occurred  in  IT  dilferent  streets,  in  18  different  blocks  and  in  19  different 
houses.  There  were  two  houses  in  which  second  fatal  cases  occurred  within  tlu-ee 
days  of  the  fii'st  case.  There  were  two  groups,  each  ha\"ing  three  fatal  cases  within 
200  yards  of  each  other.  The  two  groups  of  two  cases  each  in  a  single  family  and 
house  were  at  303  Broome  street,  100  yards  east  of  the  Bowery,  and  at  19  Mul- 
berry street,  80  yai-ds  north  of  Chathaiu.  The  two  city  gi-oups  of  300  deaths,  with 
but  a  few  days'  interval  between  the  seizm-es,  were  the  fii'st  in  Cherry  and  Oak 
near  Roosevelt  streets:  the  second  in  Mulberry  and  Baxter,  near  Chatham  street. 

"The  residences  of  the  21  fatal  cases  together,  with  10  other  non-fatal  cases, 
were  widely  scattered  over  the  city,  and  none  of  the  31  were  discovered  to  have 
been  in  any  way  directly  (!)  exposed  to  persons  or  things  from  the  quarantine  or 
from  the  emigrant  landing  or  depot.  Yet  every  one  resided  in  or  frequented  lo- 
calities that  were  daily  traversed  by  freshly  landed  emigrants;  still  no  foul  beds 
or  clothing,  or  pre^^ous  choleraic  diarrhoea,  those  good  and  sufficient  causes  of 
infection,  which  were  both  suspected  and  expected,  were  to  be  found  at  this  late 
date  of  investigation.  The  city  is  too  densely  crowded,  and  the  mixing  of  the 
population  is  too  promiscuous  and  utterly  unnoticed  and  unregistered,  to  warrant 
any  attempt  to  trace  the  connection  of  events  and  acts  that  maj'  have  occui'red 
daily  in  the  places  where  the  cholei'a  poison  was  received  into  the  system." 

The  Atlanta  had  arrived  from  Havre  in  Xov.  1865,  with  cholera  on 
board,  about  six  months  before  the  first  case  declared  itself  in  Xew  York 
on  May  1st,  or  the  near  beginning  of  warm  weather.  Germs  may  have 
wintered  over  in  strange  places.  The  first  case  was  in  East  93d  street, 
nearly  opposite  Ward's  Island,  where,  in  the  fall  of  1865,  29  persons  had 
died  of  cholera  and  were  buried.  The  privy  was  on  an  open  lot  and 
visited  by  tramps  and  persons  coming  to  and  from  Blackwell's  Island.  The 
A'irginia  arrived  from  Liverpool  April  18th,  with  31  cholera  deaths  and  66 
more  at  quarantine;  and  the  England,  April  20th,  with  267  deaths,  and 
new  germs  had  been  brought  by  2,477  emigrant  passengers.  And  this 
number  was  increased  by  the  Peruvian  with  488  passengers  and  66  deaths 
May  30th,  or  six  weeks  before  the  outbreak  on  Blackwell's  Island.  The 
first  death  was  on  Ward's  Island  after  Xovember  1865;  27  deaths  were  on 
July  21, 1866;  the  average  population,  including  50  laborers  with  13  cases 
and  deaths  from  the  Blackwell's  Island  workhouse  was  900,  with  172  deaths. 
Potter's  field  is  on  Ward's  Island,  and  a  great  proportion  of  the  poor  who 
died  of  cholera  in  Xew  York  city  Avere  buried  there  in  rough  coffins  and 
shallow  trenches.  The  State's  Emigrant  Eefuge  and  Hospital  were  sadly 
ravaged  with  cholera. 

These  gi-eat  possibilities  and  probabilities  would  have  amounted  to  cer- 
tainties if  a  more  accurate  account  of  all  the  arrivals  of  infectious  diarrhcea 
at  Ward's  and  Blackwell's  islands  and  New  York  city  could  have  been 
kept.  Xow  McGowan's  case  July  9th,  Hattou's  July  20th,  Conroy's 
July  22d,  Mary  Tracy's  July  2 1st  and  23d,  and  three  others  on  July  25th  and 
26th,  are  sufficient  to  account  for  the  great  outbreak  on  Blackwell's  Island 
on  the  night  of  July  26th  and  27th,  1866. 

To  return  to  Xew  York:  July  8th  there  were  three  fatal  cases  of 
cholera  in  characteristically  foul  localities  more  than  half  a  mile  distant 
from  each  other;  one  was  in  Cherry  street  near  Roosevelt;  one  in  Charlton 
near  Yarick,  and  one  in  Delancey  near  Pitt  street.  On  the  9th,  10th  and 
11th  there  were  four  fatal  and  two  non-fatal  cases,  one  of  them  in  a  new 
locality,  the  great  shanty  block  west  of  Central  Park,  of  which  more  anon. 


38  ASIATIC  CHOLERA. 

July  15,  four  fatal  cases  in  the  old  spots,  and  July  18tli  two  deaths  in  a 
tenement  house  120  feet  distant  from  a  previous  case  six  days  before  in 
Chrystie  street. 

In  the  first  twenty  days  of  July  there  were  only  36  deaths  in  Xew 
York  and  one  each  on  Governor's  and  Ward's  islands,  while  Brooklyn  had 
32  fatal  cases.  Total  for  July,  110  fatal  cases  in  Xew  York  and  its  insti- 
tutions, and  100  in  Brooklyn;  so  slowly  did  the  epidemic  crop  up,  as  it 
always  does  when  there  is  no  water  poisoning.  Of  numberless  other  cases 
which  recovered,  only  22  were  decided  to  be  well-marked  cholera.  The  ex- 
cessive heat  of  the  greater  part  of  July  caused  an  alarming  mortality  among 
children  from  cholera  infantum;  no  less  than  IT  per  day  for  the  first  week; 
37  daily  the  second  week;  05  the  third;  and  50  a  day  during  the  fourth 
week.     Brooklyn  Avas  affected  in  the  same  ratio. 

Summer  cholera  or  diarrhoea  is  caused  not  so  much  by  mere  heat,  as 
by  foul  heat,  Avhich  corrujDts  so  much  food,  vegetables,  meats  and  milk, 
besides  debilitating  the  body  and  perhajos  causing  vaso-motor  paralysis  of 
the  intestinal  mucous  membrane,  making  it  exhale  as  much  fluid  as  j^ours 
from  the  relaxed  skin  in  the  perspiration  of  hot  close  Aveather.  It  is  a  largely 
septic  diarrhoea  Avliich  green,  unripe  or  spoiled  fruits  and  vegetables,  and 
CA-en  meats  and  fish,  materially  aid;  and  Avhich  checked  perspiration  may 
materially  increase. 

Diarrhoeal  centers  or  fields  were  established  in  Xew  York  by  the  Aveather 
in  croAvded  and  filthy  streets,  houses,  alleys  and  courts,  Avhere  the  gutters 
were  foul  and  the  open  privies  horrible.  There  Avas  but  little  diarrhoeal 
mortality  in  the  best  and  cleanest  parts  of  the  city,  partly  because  this 
population,  Avith  their  children,  always  go  to  the  country  in  hot  weather. 
The  diarrhoeal  fields,  Avere  thought  to  be  most  common  on  the  beds  of 
former  swamp  lands,  underground  stream  beds,  and  natural  subsoil  water 
basins  that  are  undrained  to  this  day.  Still  there  Avere  some  notable  ex- 
ceptions in  shanty  toAvns  on  high  rocks  and  slaughter-house  districts  on 
rocks  Avithout  scAvers  or  other  good  drainage. 

But  the  disease  Avas  not  in  the  air,  for  in  the  midst  of  the  most  fatal 
and  most  persistent  diarrhoeal  centers  the  clean  and  well  kept  mission 
houses  Avith  croAvded  populations  of  the  poor  but  well  fed  and  Avell  washed 
children  escaped  not  only  cholera,  but  diarrhoeas  of  any  and  every  kind. 
Thus  the  FiA^e  Points  House  of  Industry,  155  Worth  street,  had  an  unpaved 
street  in  front  of  it,  damp  and  greatly  soiled  by  the  dirty  neighbors  with 
garbage.  Also  buildings  in  the  rear  and  opposite,  occupied  by  the  most 
filthy  and  degraded  beings  in  the  city,  and  among  which  cholera  raged; 
yet  out  of  200  inmates  there  Avere  only  tAvelve  cases  of  diarrhoea  and  one 
death.  The  diet  will  also  puzzle  some  choleraphobists;  bean  soup  and 
vegetable  soup,  each  tAvice  a  Aveek,  Avith  plenty  of  beef  and  mutton  boiled 
in  them.  Four  meals  a  week  of  stews  and  hash.  Indian  pudding,  hominy, 
mixed  wheat,  rye  and  Indian  bread  with  butter,  and  fruits  AAdien  obtain- 
able.    There  was  no  cholera  because  none  Avas  admitted  into  the  house. 

The  average  number  of  deaths  from  diarrhoeal  and  choleraic  disease 
for  elcA-en  A'ears  from  1854  to  18G6  was  2.567  per  A'ear;  \4z.,  from  cholera 
and  cholera  morbus;  in  1854,  2,810;  1855,  58;  1856,  56;  1857,  53;  1858, 
56;  1859,  71;  1860,  97;  1861,  85;  1862,  93;  1863,  191;  1864,  85;  1865, 
98;  1866,  1435. 

The  deaths  from  acute  diarrhoea,  dvsentery  and  cholera  infantum 
during  the  same  vears  Avere:  1854,  2,592;  "1855,  2,484;  1856,  2,302;  1857, 
2,179;  1858,  2,521;  1859,  2,124;  1860,   1,788;  1861,  1,896;  1862,  1,935; 


CHOLEEA  IX  BROOKLYX  IX  1866.-  39 

1863,  3,550;  1864,  2,488;  1865,  2,738;  1866,  3,524.  As  there  was  no 
appreciable  increase  of  mortality  from  these  diseases  in  the  great  cholera 
year  of  1854,  it  is  possible  that  the  1,200  more  in  1866  maybe  attributable 
not  to  common  cholera  but  to  Asiatic  cholera,  and  New  York  may  have 
had  1,200  more  deaths  from  cholera  in  1866  than  she  has  previously  ad- 
mitted. 

Dr.  Harris  says:  "  The  occurrence  of  1,212  fatal  cases  of  Asiatic  cholera, 
together  with  an  acknowledged  excess  of  some  2,489  fatal  diarrheal  mala- 
dies over  and  above  the  usual  mortality  should  be  fully  explained."'  Per- 
haps some  of  the  numberless  cholera  cases  reported  by  physicians  and  re- 
jected as  such  may  contain  the  explanation.  Many  old  and  weakly  persons 
die  of  cholera  before  the  previous  contents  of  the  bowels  are  fully  evacuated 
and  rice-water  discharges  appear.  Man}'  of  the  consecutive  cases  of  cholera 
assume  the  form  of  dysentery  or  at  least  have  bloody  discharges.  The 
consecutive,  or  t}i5hoid,  or  so-called  ura?mic  fevers  of  cholera  are  reported 
as  fevers.  Many  rapid  cases  of  so-called  cholera  infantum  are  cases  of 
true  cholera.  If  all  these  be  excluded  and  a  diagnosis  based  solely  on  rice- 
water  discharges  be  insisted  upon,  the  rate  of  deaths  from  Asiatic  cholera 
can  easily  be  largely  reduced,  and  apparently  justly. 

Dr.  Harris  puts  the  matter  as  plainly  as  he  can  when  he  tells  us  that 
in  the  week  ending  June  9th  there  were  2  deaths  from  cholera;  16th,  6; 
23d,  4;  30th,  1;  or  only  13  in  all.  July  7th,  3  deaths;  14th,  11;  21st, 
11;  28th,  48;  or  73  in  all,  or  only  86  in  two  months,  so  slowly  did  cholera 
increase.  If  only  the  acknowledged  cases  were  stamped  out  and  disinfected, 
many  others  must  have  escaped  sanitary  care. 

In  August  the  explosion  came,  with  239  cases  the  first  week;  258  the 
second;  145  the  third;  114  the  fourth;  so  that  the  work  of  the  health 
authorities  was  beginning  to  tell,  or  the  epidemic  to  decline.  In  Sep- 
tember, first  week,  there  were  50  fatal  cases;  second  week,  50;  third  week, 
67;  fourth  week,  54;  fifth  week,  38.  In  October,  first  week,  36;  second, 
12;  third,  5;  fourth,  3.  In  November,  first  week,  5  deaths;  second,  none; 
third,  1;  fourth,  1;  when  the  epidemic  ceased. 

In  the  same  weeks  there  were  of  cholera  infantum,  June,  first  week,  1 ; 
second,  6;  third,  13;  fourth,  40;  July,  first  week,  61;  second,  172;  third, 
278;  fourth,  176.  August,  first  week,  144;  second,  133;  third,  108;  fourth, 
122.  There  is  evidently  no  concealment  or  exaggeration  to  be  found  here. 
September,  first  week,  79;  second,  69;  third,  51;  fourth  55;  fifth,  43. 
October,  first  week,  27,  and  so  on  diminishing. 

Cholera  ix   Brooklyx  ix   1866. 

Dr.  Conklin  makes  the  report  for  Brookljm  thus: 

"  In  June  and  the  early  part  of  July,  cases  simulating  cholera  occun-ed,  but 
the  fli'st  i-eported  cases  happened  July  8th.  Its  increase  at  first  was  not  rapid  and 
mostly  confined  to  places  where  there  was  the  greatest  amount  of  filth,  especially 
in  the  southwest  12th  Ward,  which  had  many  depressed  lots  and  ponds  of  foul, 
stagnant  water.  Some  of  the  houses  were  built  on  piles  in  sunken  places,  filled 
with  garbage  and  other  foul  stuff.  There  were  no  sewei-s.  In  tliis  ward  388  cases 
out  of  816,  or  more  than  one-third,  occurred. 

"In  the  week  ending  July  13  there  were  14  cases;  July  20,  42;  July  27,  53; 
Aug.  3,  83;  Aug.  10,  161;  Aug.  17,  132;  Aug.  24,  80;  Aug.  31,  47:  Sept.  7,  81; 
Sept.  14,  28;  Sept.  21,  44;  Sept.  28,  25;  Oct.  5,  5;  Oct.  12,  5;  Oct.  19,  12:  Oct.  26,  3; 
five  more  days,  1.  Total,  816.  In  the  Hamilton  Avenue  hospital.  Dr.  Thayer  had 
thirteen  cases  in  the  first  stages,  of  which  twelve  recovered;  fifty-seven  in  the 
second,  with  fifty  deaths;  seven  in  the  third,  all  of  which  died;  showing  the  advan- 


40  ASIATIC   CHOLERA. 

tage  of  early  treatment.  Singularly  enough  the  cases  in  infants  whose  mothere 
died  of  cholera,  were  reported  as  cholera  infantum. 

"  The  average  duration  of  cases  fatal  in  the  second  stage  was  thirty-one  hours; 
shortest,  eight  hours;  longest,  seventy-five  hours.  The  average  of  the  third  stage 
fatal  cases  was  nine  days;  shortest,  five  days;  longest,  twenty  days.  In  tliese,  cases 
of  consecutive  fever  were  included. 

"  In  the  Brooklyn  City  Park  Hospital  there  were  eighteen  cases  and  eleven 
deaths,  mostly  admitted  in  collapse.  Tlie  main^treatment  was  calomel,  ten  g-rains 
at  first  dose,  then  one  grain  every  hour;  green  tea  and  brandy.  For  bloody  dis- 
charges, injections  of  lavidanum  and  gum  water.  The  effect  was  good.  After 
reaction,  beef  tea  and  stimvdants.  with  teaspoonful  doses  of  paregoric,  which  were 
generally  sufRcient  to  control  subsequent  looseness  of  the  bowels. 

"  In  the  county  jail  tliere  were  thirty-six  cases  in  a  sliort  time  after  July  31st. 
It  was  stamped  out  in  thirteen  days  by  moving  the  patients  to  tents,  change  of 
diet  and  disinfection.  The  first  case  was  May  33d,  possibly  merely  septic  cholera, 
in  a  man  digging  a  trench  soaked  with  excrements.  The  second  case  was  July 
21st,  or  two  months  after;  the  tliird  on  the  34tli,  and  then'every  day  tliere  were  a 
few  cases  until  Aug\  3d,  when  there  were  no  new  cases  for  one  day;  but  on  the 
night  of  Aug-.  3d,  no  less  than  thirty-eight  cases  of  the  most  malignant  character 
occurred,  with  twenty-two  deaths  in  twenty-four  hours.  The  building-  was  vacated, 
and  fifty  prisoners  for  slight  offenses  were  discliarged.  No  treatment  seemed  of 
any  avail.  In  all  there  were  eighty-seven  cases  and  sixty-seven  deaths.  The 
initial  case  was  not  discovered,  but  the  outbreak  was  possibly  due  to  imperfection 
in  the  water  pipes,  which  were  laid  in  the  trench  soiled  with  excrements,  on  May 
33d.  There  were  fifty-five  deaths  from  so-called  cholera  morbus  in  July,  seventy- 
two  in  August,  fifteen  in  September;  total,  one  hundred  and  forty- two,  which  is 
unprecedented.  Outside  of  tlie  Twelfth  and  Sixtli  Wards,  the  mortality  was  in- 
significant, except  the  sudden  and  overwhelming  outbreak  in  the  penitentiary  in 
the  Ninth  Ward.  This  building  is  on  tlie  summit  of  a  hill;  the  drainage,  ventila- 
tion and  cleanliness  vinexceptionable.  But  at  the  foot  of  the  hill  are  large  stag- 
nant pools,  cow  stables,  and  pig  yards.  On  the  night  of  the  outbreak  the  air  was 
hot  and  damp,  with  scarcely  breeze  enough  to  move  away  the  poisonous  vapors 
whicli  overflowed  tlie  plain  and  permeated  the  penitentiary.  Tliere  was  no 
Asiatic  cholera  in  Brooklyn  in  June,  but  thirty-three  deaths  from  cholera  infantum, 
and  thirty-eight  deaths  from  acute  diarrhoea,  dysentery  and  cholera  morbus  m 
adults.  The  firet  cases  in  the  penitentiary  were  on  July  31st  and  34th;  then  none 
till  the  night  of  Aug.  3d,  when  there  were  thirty-eight  severe  cases,  nearly  four- 
teen per  cent,  of  the  inmates,  four-sevenths  of  whom  died,  or  eight  per  cent,  of  the 
whole  residents.  Five  assistant  keepers  and  one  nurse  were  also  attacked.  The 
importation  was  not  traced,  except  that  in  the  Raymond  street  jail  neax'ly  one- 
half  of  the  inmates  were  destroyed,  and  that  the  penitentiary  was  supplied  every 
week  with  new  imiiates  directly  from  this  jail." 

No  one  has  yet  ever  positively  puzzled  out  the  initial  cases  in  New 
York,  Brooklyn  or  BlaekwelFs  Island.  They  were  detected  at  once  on 
Governor's  Island  by  the  military  surgeons.  There  was  abundance  of 
opportunities  for  importation  in  all  these  places;  and  importation  doubt- 
less did  take  place,  but  in  large  cities  and  institutions  the  non-fatal  diar- 
rhoeal  cases  necessarily  do  not  attract  much  attention;  probably  not  a  tithe 
of  them  run  on  to  fully  developed  cholera;  still  more  are  cured  by  early 
treatment;  but  they  are  all  infective.  The  unwashed  hands  of  the  diar- 
rhoeal  cases  are  probably  the  first  agents  in  the  conveyance  of  the  disease; 
next  the  vomits  which  are  apt  to  go  over  bed  and  body  clothes,  and  on 
floors.  The  towels  and  basins  come  next.  Then  the  discharges,  which  go 
into  privies  and  the  soakage  from  them  into  wells  of  drinking  water. 
Bread,  cake,  fruit,  and  vegetables  handled  by  persons  with  incipient 
diarrhoea  are  great  agents  in  the  distribution  of  the  disease,  and  however 
good  or  ripe  these  articles  may  be,  they  are  more  dangerous  than  uncon- 
taminated  green  apples,  cucunibers,  soft  crabs  and  lobsters,  to  say  nothing 
of  water-melons,  which  are  doubtless  as  harmless  as  eggs,  as  the  soiled 
rinds  are  never  eaten. 


CHOLERA  IN  ASIA  IN  1869.  ^l 


CHAPTER  VITI. 

THE  CHOLERA  WHICH  REACHED  THE  UNITED  STATES  IN  1873. 

The  great  Bombay  and  Mecca  cholera  of  1865  still  lingered  in  Persia 
in  1867,  especially  in  Tehei'an,  the  capital,  near  the  foot  of  the  Caspian 
sea.  This  was  early  in  the  summer.  The  outbreak  was  probably  a  reap- 
pearance of  the  epidemic  of  the  previous  year.  In  1867  the  great 
twelfth-year  Juggernaut  epidemic  of  1865  was  supplemented  by  the  Hurd- 
war  outbreak,  in  which  three  millions  of  pilgrims  were  involved  in  the  ex- 
treme north  of  India,  and  was  carried  through  the  Bolan  pass,  went  into 
Afghanistan  and  also  through  the  Kyber  pass  to  Cabul.  The  pestilence 
raged  with  almost  unprecedented  .violence  in  Afghanistan  early  in  July, 
1867,  and  appeared  in  numerous  places  along  the  road  from  Herat  to 
Meschid  and  Teheran;  and  was  even  on  its  old  march  up  between  the 
Black  and  Caspian  seas.  I  have  already  alluded  to  Hurdwar  and  this  route, 
but  it  is  necessary  now  to  dwell  upon  them  more  fully. 

Cabul  is  the  first  great  to\vn  to  the  northwest  over  the  bordei"s  of  the  British 
possessions  in  India.  It  is  the  grand  center  of  the  trade  of  India  with  Persia, 
Central  Asia,  and  Russia.  It  is  the  southern  terminus  of  the  Russian  commerce 
with  Hindostan,  and  has  long  been  the  theater  of  the  commercial  and  political 
rivalry  of  Russia  and  England,  in  their  attempts  to  control  Persia  and  Central 
Asia.  Cholera  is  regularly  brought  up  to  Cabul  from  Hurdwar,  through  Lahore, 
Attock,  and  Peshawur,  and,  although  it  is  called  "the  city  of  100,000  gardens," 
pai-ts  of  it  are  well  adapted  to  mviltiply  the  infection  of  cholera.  Many  of  its 
small  streets  are  built  over,  forming  low,  dark  tunnels,  containing  every  offensive 
thing.  Water  collects  and  stagnates  in  ponds  all  over  the  city;  the  inhabitants 
cast  out  the  refuse  of  their  houses  into  the  streets;  and  dead  dogs  and  cats  are 
frequently  seen  lying-  on  heaps  of  the  vilest  filth,  while  dead  horses  occasionally 
pollute  the  air  for  many  days  together. — Sir  Arthur  Connolly. 

The  traffic  between  Russia,  Pei-sia,  Central  Asia  and  India,  by  way  of  Cabul,  is 
made  under  curious  conditions,  which  have  descended  from  high  antiquity;  for  it 
belongs  to  four  tribes  of  Lohanee  Afghans,  called  P)'ovindahs,  who  are  both 
pastoral  and  mercantile  in  their  pursuits,  and  number  8,000  families,  with  over 
30,000  camels  and  10,000  oxen  of  transport.  They  organize  themselves  into  three 
immense  caravans,  which  resemble  vex'itable  corps  d'armee,  and  descend  into 
India,  not  only  in  time  to  attend  the  great  fair  at  Hurdwar,  but  also  to  penetrate 
down  the  Ganges  to  Benares,  and  along  the  Indus  to  Kurrachee,  and  thence  by 
sea  to  Bombay.  They  bring  down  Russian,  Persian  and  Afghanistan  articles  of 
trade,  and  retui-n  with  cotton  goods,  muslins,  shawls,  silks,  brocades  and  in- 
numerable other  articles.  The  first  great  division  has  20,000  to  30,000  camels, 
numerous  oxen,  and  50,000  to  60,000  head  of  sheep;  the  second  division,  10,000  to 
17,000  camels  and  a  proportionate  number  of  oxen  and  sheep;  and  the  third  divi- 
sion, 3,000  to  5,000  camels.  These  all  return  to  Cabul  and  Candahar  by  the  middle 
of  June,  in  time  to  dispatch  their  investments  on  to  Herat  and  Meschid  in  the 
west,  and  to  Balk  and  Bokhara  in  the  northwest.  They  also  always  descend  again 
into  India  bj'  the  end  of  October,  with  36  different  Russian  articles,  and  return 
with  64  kinds  of  English  and  India  goods.  From  1,500  to  2,000  camels  are  alone 
employed  in  conveying  pomegranate  rinds,  which  dress  leather  in  a  sujjerior  man- 
ner; 3,000  camels  carry  coarse  cotton  cloths  from  India  to  Cabul;  five  caravans 
with  shawls,  from  the  16,000  looms  in  Cashmere,  have  arrived  in  Cabul  in  one 


42  ASIATIC  CHOLERA. 

year;  much  salt  is  carried  up  from  the  inexhaustible  mines  at  Lahore;  many 
thousand  camel-loads  of  fresh  and  dried  fruits  are  brouglit  down  to  India;  and 
Russian  goods  are  so  cheap  and  common  in  Cabul,  at  times,  that  looking-g-lasses 
large  enough  to  serve  as  window-panes  are  sold  for  half  a  dollar.  In  addition, 
there  is  a  great  Hindoo  festival  on  the  banks  of  the  Indus,  near  Attock,  eveiy 
April,  to  which  great  crowds  congregate.  Pilgrims  also  come  down  from  Cabul 
to  the  river  Indus,  which  they  descend  to  the  sea  and  then  pass  on  to  Mecca;  and 
a  great  Mohammedan  festival  takes  place  on  the  28th  of  March.  Such  are  the 
causes  which  propel  cholera  up  from  India  to  Candahar  and  Cabul. — Sir  Alex. 
Burues. 

From  Cabul,  the  disease  is  always  carried  due  west  to  Herat.  Occasionally,  it 
has  happened  that  a  single  ti'aveler  or  pilgrim  could  proceed,  unai-med,  from 
Cabul  to  Herat.  But,  generallj',  the  merchants  and  devotees  travel  in  great  cara- 
vans, with  long  strings  of  camels.  They  are  armed  to  the  teeth,  and  often  bear  the 
marks  of  many  a  conflict.  Now  and  then  some  pi-ince,  like  the  son  of  the  King 
of  Lucknow,  comes  up  with  a  large  suite  of  Indo-Mohammedans;  and  it  is  thought 
that  over  60,000  pilgrims  pass  through  Herat  eveiy  year,  on  their  way  west  to  the 
holy  city  of  Meschid. 

Herat  has  at  least  50,000  inhabitants,  and  is  a  well  known  town;  but  in  1857, 
the  London  Times  asked,  "AVhere  is  Herat?"  It  is  in  the  extreme  northwestern 
corner  of  Afghanistan,  and  stands  in  the  same  relation  to  this  province  thatPesh- 
awur  does  to  India;  for  it  is  the  only  gate  by  which  it  can  be  approached  from  the 
west.  All  the  practicable  roads  from  Persia  and  Central  Asia  converge  and  unite 
as  they  approach  Herat.  It  is  the  door  and  citadel  which  must  be  opened  before 
caravans  and  armies  from  Persia  and  the  west  can  reach  Afghanistan  and  Hindo- 
stan.  Its  situation  is  one  of  the  greatest  military  and  commercial  importance ; 
for  the  peaceful  files  of  the  caravan  and  the  dread  battalions  of  war  must  alike 
pass  through  it  on  their  way  from  India  to  Persia,  and  from  Pei'sia  to  India. 
Long  camel  trains,  coming  vip  from  Delhi,  Moviltan,  Hurdwar,  and  Lahore, 
traverse  it,  bearing  the  products  of  India  and  the  manufactures  of  England  to  the 
distant  towns  and  oases  of  Persia  and  Turkestan.  So  completely  is  Hei"at  a  gate- 
way of  commerce,  that  is  called  a  "  bunder,''  or  port,  although  the  only  seas  upon 
which  it  borders  are  seas  of  sand.  The  march  of  conquest  has  led  through  it  from 
time  immemorial,  especially  after  the  time  of  Mohammed.  Since  A.D.  710,Jiost 
after  host  of  fierce  warriors,  led  by  the  Kaliphs  of  Damascus  and  Bagdad,  of  Syria 
and  western  Persia,  coming  almost  from  the  borders  of  the  Caspian,  Black  and 
Mediterranean  seas,  have  cari'ied  the  tassels  of  the  Mohammedan  flag  victorious- 
ly down  into  India.  The  vast  and  fertile  plain  about  Herat  has  often  been  a  huge 
2>lace  d'ainnes,  where  all  the  assembled  columns  from  the  west  have  united  and 
recruited  before  making  their  final  descent  upon  Hindostan,  and  it  has  often  beett 
predicted  that  the  Cossack  and  the  Sepoy  must  sooner  or  later  rneet  there  in 
deadly  strife.  No  better  camping-ground  and  quai-ters  have  ever  been  found  for 
caravans  and  armies.  Abundant  crops  of  wheat  and  barley,  and  every  kind  of 
fruit  known  to  Persia,  grow  there  in  profusion.  Cattle  and  sheep  abound.  The 
bright  waters  of  the  river  are  as  "clear  as  tears,"  and  numerous  running  streams 
and  artificial  canals  light  up  the  pleasant  landscape  and  fertilize  the  soil.  Such  is 
the  profusion  of  roses,  that  it  is  called  the  "  City  of  Roses,"  and  a  very  large  pro- 
portion of  the  whole  world's  supply  of  the  celebrated  "Attar"  comes  from  it.  But 
there  are  other  smells  than  those  from  roses  about  Herat.  At  night,  on  the  road, 
one  is  apt  to  be  awakened  by  the  shouts  of  drivers  and  the  tinkling  of  bells,  an- 
nouncing a  passing  caravan,  and  bj'  the  faint  light  of  the  moon  perceives  a  sea  of 
long,  black  boxes  surging  by  on  scores  of  mules  and  camels.  Each  animal  is 
laden  with  two  of  these  horrible  objects,  one  on  each  side,  and  many  of  them  are 
so  loosely  nailed  together  that  another  sense  than  that  of  smell  soon  convinces 
one  that  they  are  vised  as  coffins.  In  fact,  they  contain  the  bodies  of  the  devout, 
wlio,  having  died  in  the  true  faith,  are  now  being-  taken  to  be  buried  in  holy 
ground  at  Kerbela  or  Meschid.  They  are  often  carried  hundreds  of  miles,  and  a 
sickening  stench  always  comes  up  from  their  gaping-  fissures,  causing  nausea  and 
faintness  in  the  drowsy,  unsuspecting-  traveler,  who  finds  it  impossible  to  extricate 
himself  promptly  from  their  neighborhood;  for  they  come  crowding  on  in  the 
dark  as  if  there  were  no  limit  to  their  nvunbers. 

The  cholera  of  1828  swept  away  many  thousands  in  Herat,  although  water, 
that  prime  necessity  of  Oriental  life,  is  so  abundant  that  almost  every  hovise  has  its 
fountain,  besides  the  large  public  ones  in  the  streets  and  bazaars.  Each  successive 
epidemic  of  the  disease  in  Hindostan  has  reached  Herat,  and  been  carried  on 


CHOLERA  IN  ASIA  AND  EUROPE  IN   1871.  43 

through  Pei-sia  to  Turkey  and  Russia.  That  of  1841  reached  CabLil  in  June; 
Herat  in  August;  Meschid  in  September;  and  Teheran  in  October. 

Tlie  next  important  town  due  west  of  Herat  is  Meschid.  Tliis  is  so  holy  that 
no  person  of  any  sect  called  Mohammedan  has  ever  dared  to  commit  the  impiety 
of  firing-  a  hostile  shot  at  its  walls.  For  eight  months  in  the  year  all  the  roads  to 
and  from  Meschid  are  thronged  with  pilgrims.  Nearly  60,000  come  up  from  India, 
Cabul  and  Afghanistan;  and  as  many  more  from  the  south  of  Persia.  Over  100,- 
000  crowd  on  fanatically'  from  Turkey  in  Asia  and  the  Caucasus  in  the  west;  and 
perhaps  an  equal  number  from  the  north. 

Connolly  says  the  distant  cities  in  which  the  pilgrims  assemble  and  make 
themselves  up  into  caravans,  to  go  to  Meschid,  are  so  thronged  with  men  and 
animals  that  there  is  scai-celj'  passage  through  the  crowd.  Horses,  mules,  camels, 
and  cattle  are  picketed  the  entire  length  of  the  outer  walls,  where  they  neigh, 
bray  and  fight,  while  their  masters  are  busy  currying  or  shoeing  them;  mending 
pack-saddles;  higgling  for  supplies  of  straw  or  corn;  or  sleeping,  praying,  or  i-ead- 
ing  the  Koran. 

The  pilgrims  g'enerally  travel  at  night;  some  of  them  carry  torches,  and  at  the 
head  of  the  line  a  pot  of  live  charcoal  swings  under  the  belly  of  a  horse,  to  light 
their  pipes  and  mark  the  line  of  march.  In  cool  and  pleasant  weather  they  move 
by  day.  Gay  pennons  are  then  unfurled,  and  all  go  on  with  light  hearts. "  From 
time  to  time,  their  leaders  raise  a  shout  for  the  blessed  Mohammed,  and  if  their 
followers  do  not  join  in  loudly  and  unanimously-,  they  are  urged  to  do  "better 
than  that,"'  "sweeter  than  that,"  angels  are  called  upon  to  aid  them,  till  finally 
the  air  is  rent  with  fervent  and  inspiring-  cries,  which  makes  one's  very  heart's 
blood  boil.  Going  and  returning  pilgrims  greet  each  other  on  the  road.  Many 
others  are  seen  encamped  at  the  roadside;  the  poorer  pilgrims  in  miserable  tents 
and  shelters,  but  the  richer  Turks  and  Pereians  in  gi'een,  skj'-blue  or  white  tents, 
surmounted  by  gilt  balls  and  crescents,  and  lined  with  costly  carpets.  AVell-clad 
male  and  female  servants,  in  numberless  groups,  walk,  recline,  sit,  smoke  or  chat 
in  and  about  the  camps.  Hundreds  of  hoi'ses,  riclily  caparisoned  graze  around. 
Huge  piles  of  baggage  and  provisions  are  guarded  by  trusty  soldiers,  bristling  to 
their  chins  with  silver-hilted  daggers  and  inlaid  pistols,  the  whole  bearing  an 
air  of  wealth,  pomp,  and  security. 

The  scene  is  more  wild  and  strange  when  the  pilgrims  halt  at  caravansaries. 
The  noise  and  quarreling,  at  first,  can  only  be  imagined  by  those  wlio  have  seen 
Persians  on  the  march.  But  the  leader  of  the  caravan  soon  takes  his  place  in  the 
middle  of  the  sqviare,  and  commences  reciting  prayei-s  and  verses  in  honor  of  the 
Prophet,  to  which  the  pilgrims  shout  short  sentences  from  the  Koran  in  reply. 
Connolly  says  the  effect  of  their  voices  coming-  from  the  cells  on  all  sides  is  very 
wild  and  pleasing,  especially  at  night,  when  the  sounds  g-raduallj' rise,  cliiniingin 
with  each  other  till  they  are  perfectly'  blended  in  one  full  chorus.  But  soon  all 
fall  asleep  and  silence  reigns  in  cells  which  are  so  filthy  that  few  Europeans  can 
remain  in  them. 

Finally,  the  holy  city  is  reached,  and  several  times  in  the  course  of  eveiy  day 
dense  troops  of  soiled  and  jaded  pilgrims  and  travelers  pass  through  the  city  gates 
of  Meschid,  into  the  gi-eat  square,  which  is  usually  crowded  with  people  from  all 
pai'ts  of  the  East;  with  Afghans,  Arabs,  Koords,  Turks,  Osbegs;  with  pilgrims 
from  all  the  provinces  of  Persia;  with  priests,  merchants,  peasants  and  dervishes, 
■without  number,  from  the  borders  of  the  Caspian  and  Black  seas,  and  from  the 
Pei-sian  gulf.  The  great  and  magnificent  square  is  approached  from  two  sides  by 
very  high  arched  gates,  of  exquisite  architecture,  faced  with  brilliant  blue-enam- 
eled tiles.  On  the  other  two  sides  are  deep  ai-clied  porches,  of  the  same  height 
and  proportions  as  the  gates,  but  covered  with  copper  tiles,  heavily  gilt.  One 
porch  leads  into  a  fine  mosque;  the  other  faces  a  high,  gilded  minaret,  and  the 
golden  dome  under  which  rest  the  sacred  remains  of  the  Iman.  The  space  be- 
tween the  gates  and  porches  is  inclosed  on  all  sides  by  a  double  story  of  arched 
cloisters,  fronted  with  mosaic  work  and  paved  with  the  gorgeous  gravestones  of 
rich  and  holy  men.  A  stone  canal  conducts  water  through  the  center  of  the 
square  for  the  ablutions  of  the  faithful,  and  beautiful  shade  trees  abound.  The 
midday  sunbeams  are  reflected  gorgeously  from  the  manj'-colored  and  golden  tiles; 
and  the  light  of  the  declining  iuminarj-  falls  glowing  upon  the  resplendent  dome. 
But  the  most  glorious  effect  is  produced  when  rain  falls  wiiile  the  sun  is  breaking 
through  light  clouds,  causing  the  large  drops  which  are  shed  from  the  golden  tiles 
to  glitter  like  enormous  diamonds.     This  sparkling  shower  on  the  gilt  dome  is 


44  ASIATIC  CHOLERA. 

often  worshiped  as  a  downpour  of  heavenly  Hght,  and  excites  the  i>ilgi'inis  to  a 
perfect  frenzy  of  enthusiasm. 

But  Meschid  presents  other  sights  and  sounds  than  those  of  rehgion  and 
pleasantness.  Hundreds  and  thousands  of  beggars,  of  the  most  miserably  squalid 
appearance,  beset  every  approacli  to  the  shrine,  waylaying  the  pilgrims  in  every 
direction.  Old  men  and  women,  in  the  most  abject  states  of  want  and  misery, 
throng  the  streets,  which  are  also  strewn  with  cliildren  not  more  than  two  or 
three  years  old,  grovelling  in  tlie  dirt,  mere  living  skeletons,  more  like  starved 
yoving  animals  than  human  ci-eatures.  Some  are  crying  and  sending  forth  piteous 
petitions  with  their  little  half-quenched  voices;  othei-s,  silent,  lying  like  dead 
things;  others,  listless  and  motionless,  but  with  a  wolf-like  glare  of  hunger  in 
their  sunken  eyes,  giving  terrible  evidence  of  the  fierce  pangs  which  gnaw  within 
them.  Blear-eyed  girls  and  filthy  boys  carried  things  like  starved  cats  in  their 
arms,  all  squalling  for  bread.  Fraser  ran  the  gauntlet  of  a  crowd  of  specters  of 
this  kind  nearly  half  a  mile  long.  Most  of  them  were  the  wives  and  children  of 
Tui'comans  from  the  eastern  borders  of  the  Caspian  Sea,  whose  towns  had  been 
sacked  by  the  Meschidees.  The  able-bodied  men  and  women  had  been  sold  as 
slaves,  and  the  old  people  and  children  thus  left  to  beg  or  starve.  As  manj^  as 
3,000  to  4,000  persons  have  been  brought  into  Meschid  at  one  time,  and  the  feeble 
left  to  the  tender  mercies  of  pilgrims  and  strangers. 

Cholera  is  always  carried  from  Meschid  to  Astrabad,  on  the  east  coast  of  the 
Caspian  sea,  by  merchants  and  pilgrims,  and  then  forwarded  up  to  Astrakhan.  It 
is  also  conveyed  from  Meschid  to  Teheran,  the  capital  of  Persia,  situated  only  70 
miles  south  of  the  lower  border  of  the  Caspian  Sea. 

Cholera  had  almost  completely  died  out  in  Europe  in  1868,  especially 
in  Eussia,  when  suddenly  in  July,  1869,  it  was  heard  of  at  Kief,  the  holy 
city  of  southwestern  Eussia,  on  the  river  Dnieper,  about  100  miles  above 
its  mouth  at  Odessa,  on  the  Black  sea.  From  June,  1869,  there  had  been 
numerous  cases  of  choleraic  diarrhoea  at  Kief,  but  up  to  October  only  69 
cases  of  fatal  algid  cholera,  and  up  to  Dec.  11,  only  115  cases  in  all.  In 
July,  August  and  September,  1869,  it  also  broke  out  at  the  great  fair  of 
Nijni  Novgorod,  just  east  of  Moscow,  to  which  over  200,000  merchants 
assemble  from  all  parts  of  Eussia,  Persia,  Central  Asia  and  many  other 
places;  but  the  pestilence  was  not  acknowledged  until  after  the  fair  had 
come  to  an  end  and  the  people  had  dispersed.  There  is  doubt  whether 
the  pestilence  commenced  at  Kief  or  Nijni.  Cholera  had  previously 
reached  Tiflis,  near  the  pass  of  Dariel,  and  a  line  of  railroad  had  been 
built  from  it  in  1867  to  Poti  on  the  east  coast  of  the  Black  sea,  from 
wiience  steamships  ran  regularly  to  Odessa.  A  railroad  to  Kief  had  also 
just  been  opened,  so  that  cholera  might  easily  and  quickly  have  been  con- 
veyed to  Kief.  But  a  railroad  had  also  been  built  throiTgh  the  pass  of 
Dariel  directly  up  into  Eussia  toward  Moscow  and  Nijni,  and  cholera  could 
have  traveled  equally  rapidly  that  way.  However  this  may  be,  tliere  were 
911  fatal  cases  in  Eussia  in  1869;  no  less  than  20,140  in  1870;  and  the 
enormous  number  of  305,220  in  1871. 

Canals  connect  the  river  Dnieper,  which  runs  south  to  the  Black  sea, 
with  the  rivers  Niemen,  Vistula  and  Oder,  which  run  north  to  the  Baltic. 
Over  40,000  Polish  raftsmen  ply  these  streams,  and  in  1871  and  1872 
Poland  had  37,586  cases  of  cholera;  Galiciahad  38,448;  Hungary  433,295, 
from  1871  to  1873;  Prussia  37,000.  Altona  near  Hamburg  became  involved 
as  early  as  August  9,  1871,  and  Hamburg  itself  by  August  28,  and  even 
sliipped  it  by  the  ship  Alster  to  England  in  September.  In  August,  1872, 
there  were  107  cases  in  one  week  in  Hamburg,  and  tliere  were  1,225 
cases  in  that  city  in  1873.  On  Oct.  10,  1871,  the  steamship  Franklin  left 
Stettin  on  the  Baltic  and  arrived  at  Halifax,  Nov.  6,  having  lost  40  of 
her  passengers,  and  then  came  on  to  New  York.  Suddenly  in  Feb.,  1873, 
cholera  commenced  at  New  Orleans.     The  first  victims  were  a  Frenchman 


THE  EPIDEMIC  IN  THE  UNITED  STATES  IN  1873.  45 

and  German,  but  they  were  old  residents.  The  Bremen  and  Hamburg 
steamships  running  to  New  Orleans,  which  touch  at  Havre,  were  suspected, 
but  nothing  could  be  proved.  Whether  the  first  victims  received  soiled 
goods  or  visitors  from  Europe  no  one  knows.  But  the  Xew  Orleans 
authorities  had  something  to  conceal,  as  the  published  shipping  lists  will 
show.  The  Secretary  of  State  asked  for  a  list  of  the  cases  of  sickness  and 
deaths  at  sea  on  board  the  vessels  arriving  at  Xew  Orleans  in  January 
and  February,  1873;  and  the  subjoined  was  all  that  could  be  obtained; 
everything  was  given  except  what  was  asked  for.  Even  the  names  of  the 
regular  steamships  plying  to  Havre,  Bremen  and  Hamburg  Avere  omitted. 
It  is  sufficient  to  say  that  the  same  quarantine  officer  let  in  the  yellow 
fever  of  1873,  and  was  then  dismissed.  In  Januar}^,  1873,  two  vessels 
arrived  from  Havre,  one  each  from  Antwerp,  Leghorn,  Rio  Janeiro  and 
Bristol;  ten  from  Havana,  all  of  which  places  are  said  to  have  had  cholera. 
In  February,  there  were  arrivals  from  Rio  Janeiro,  Genoa,  Italy, 
Havre,  Antwerp,  Messina  and  Sicily,  all  of  which  were  infected.  The 
number  of  passengers  on  52  vessels  was  not  given,  nor  the  sickness  and 
deaths  among  these  and  the  crews.  There  was  strictest  concealment;  but 
we  have  already  seen  how  difficult  it  is  to  track  down  the  initial  cases  in 
large  cities. 

Epidemic  Cholera  in  the  United  States  in  1873.' 

The  earliest  recognized  case  of  epidemic  cholera  in  the  United  States 
during  the  year  1873  occurred  in  the  city  of  New  Orleans,  La.,  on  Feb- 
ruary 9.  It  was  impossible  to  determine  any  connection  between  this  and 
other  early  cases  of  the  epidemic  and  the  occurrence  of  any  imported 
cholera  case;  but  many  essentials  of  an  outbreak  of  epidemic  cholera  were 
most  positively  determined.  It  was  found  that  during  the  last  month  of 
1872  and  the  first  six  months  of  1873,  three  hundred  and  forty-two 
vessels  arrived  at  New  Orleans  from  European,  West  Indian  and  South 
American  ports.  That  these  vessels  carried  into  the  port  of  New  Orleans 
four  thousand  two  hundred  and  forty-nine  passengers,  the  majority  of 
Avhom  were  emigrants;  and  seven  thousand  two  hundred  and  forty-nine 
officers  and  crcAv;  a  grand  total  of  eleven  thousand  four  hundred  and 
ninety-eight  individuals.  The  statistics  of  emigration  showed  that  of  the 
six  thousand  and  seventy-nine  emigrants  received  at  New  Orleans  during 
1873,  only  two  hundred  and  ten  were  from  West  Indian  and  South 
American  ports.  The  majority  of  emigrants  Avere  shipped  at  Bremen, 
Hamburg,  Havre  and  Liverpool.  It  was  further  found  that  the  quaran- 
tine upon  the  Mississippi  river  in  1873  had  been  Avorse  than  useless;  that 
emigrants  and  their  effects  Avere  passed  without  questions;  that  the  ma- 
jority of  emigrants  in  New  Orleans  were  lodged  in  tenement  houses  on 
the  levee,  and  on  that  portion  at  Avhich  coast  and  river  steamers  land.  It 
was  further  found  that  the  first  tAventy-five  fatal  cases,  those  Avhich  oc- 
curred in  the  months  of  February  and  March,  could  one  and  all  be  traced 
to  their  daily  avocations  on  or  near  the  steamboat  levee,  and  to  each  other. 
It  Avas  further  found  that  no  record  of  diarrhoeal  or  non-fatal  cholera  cases 
Avas  attempted  until  it  Avas  too  late  to  obtain  any  information  of  them. 

At  NcAv  Orleans,  the  epidemic  influence  lasted  from  February  to  Novem- 
ber, 1873,  having  a  total  of  two  hundred  and  fifty-nine  deaths.  The  total 
number  of  those  avIio  Avere  attacked  by  the  disease  can  never  be  deter- 

'  This  part  of  the  chapter  is  from  the  pen  of  Dr.  Ely  McClellan. 


46  ASIATIC  CHOLERA. 

mined.  The  epidemic  influence  did  not  spread  over  the  entire  city,  but  was 
confined  to  the  central  and  tlie  oldest  portions.  Cholera  Avas  carried  from 
Xew  Orleans  to  nine  different  parishes  of  the  State.  The  most  active  agents 
in  this  diffusion  were  coast^  river  and  trading  boats,  as  they  had  been  in 
all  former  epidemics. 

From  New  Orleans  the  progress  of  cholera,  was  first  confined  to  the 
line  of  the  Mississippi  river.  At  Vicksburg,  Miss.,  the  first  authentic 
case  occurred  May  13,  when  the  epidemic  was  at  its  worst  in  New  Orleans. 
It  is  very  probable  that  the  infection  of  the  initial  case  was  from  river 
steamers.  That  these  boats  were  cholera  infected  was  shown  by  the  fact 
that  on  May  14  the  steamer  John  Kilgore,  from  New  Orleans  to  Cincinnati, 
0.,  called  at  Vicksburg  having  on  board  a  violent  case  of  cholera,  for  whom 
the  services  of  a  Vicksburg  physician  were  obtained. 

Very  little  information  could  be  obtained  as  to  the  epidemic  on  the 
lower  Mississippi;  my  efforts  almost  always  ended  in  failure.  A  modified 
epidemic  occurred  at  Jackson,  the  capital  of  Mississippi.  From  Dr.  T.  I. 
Mitchell  I  obtained  the  interesting  history  of  one  group  of  cases.  A 
negro  girl,  who  was  emj)loyed  as  a  servant  in  a  Jackson  family,  was  taken 
with  cholera  and  died.  Her  father  and  his  family  lived  in  the  country 
some  miles  from  the  city.  The  day  the  girl  died,  the  father  removed  all 
her  effects,  including  the  bed  on  which  she  died,  to  his  home  in  the  coun- 
try. One  week  later  the  entire  negro  family,  consisting  of  seven  individ- 
uals, had  cholera,  and  all  died  but  one.  Doctor  J.  A.  Tillman  reported 
several  outbreaks  of  cholera  upon  plantations  in  what  is  known  as  the  Deer 
Creek  district;  and  includes  the  instance  of  a  negro  man  who  stole  some 
articles  of  clothing  from  a  cholera-infected  house,  which  articles  he  carried 
home.  Three  days  later  this  man,  his  wife  and  three  children  all  had 
cholera.  The  woman  alone  recovered.  The  city  of  Natchez,  Miss.,  es- 
caped this  epidemic,  as  it  had  escaped  all  previous  epidemics.  A  most 
perfect  sanitary  condition  was  maintained.  Quarantine  regulations  were 
strictly  enforced.     The  water  supply  was  pure. 

In  the  State  of  Arkansas,  the  earliest  cases  were  at  Osceola  on  April  17. 
A  man  who  had  Just  returned  from  Memphis  was  taken  with  cholera  in 
a  miserable  hut,  which  was  occupied  by  ten  other  persons.  The  first  case 
died  in  a  few  hours.  Three  other  cases  followed,  when  all  were  removed 
from  the  hovel,  and  the  disease  was  stamped  out.  Sept.  8,  a  second  out- 
break occurred,  which  was  traced  to  river  boats,  and  the  epidemic  was 
confined  to  a  few  filthy  negro  huts.  At  Pine  Bluff,  a  man  living  on  the 
Arkansas  river,  near  the  steamboat  landing,  was  taken  with  cholera  June 
25,  and  died  the  next  day.  June  30,  his  son-in-law,  who  lived  in  the  same 
house,  was  taken  and  died  in  24  hours.  July  3,  the  wife  of  the  last  case 
was  attacked  but  recovered.  July  5,  a  man  who  had  nursed  the  preceding 
cases  died  of  cholera;  the  same  day  a  negro  servant  of  the  last  case  was 
taken  sick  and  died  the  next  day. 

In  the  city  of  Little  Eock,  four  distinct  importations  of  cholera  oc- 
curred. Each  were  sufficient  to  have  created  an  epidemic,  and  each  would 
undoubtedly  have  been  successful  but  for  the  active  sanitary  measures 
employed.  June  29,  a  young  woman  from  some  point  on  the  Cairo  and 
Little  Eock  railroad,  returned  to  the  city  and  went  to  her  home  in  a  tene- 
ment house,  where  she  was  taken  with  cholera  and  died  after  an  illness  of 
twelve  hours.  Every  precaution  was  taken  to  isolate  the  case,  and 
no  spread  of  the  disease  occurred.  July  2,  a  negro  deck  hand  from  a 
Memphis  steamer  was  admitted  late  at  night  to  the  county  almshouse. 


THE  EPIDEMIC  IN  THE  UNITED  STATES  IN  1873.  47 

He  was  sick  with  cholera,  but  he  was  placed  in  a  miserable  hut  with  other 
negroes,  and  his  case  was  not  reported  until  early  the  next  day,  when  he 
was  found  in  the  stage  of  collapse.  The  excreta  had  during  the  night 
been  thrown  out  around  the  hut.  At  daylight  Dr.  Dale,  being  called,  at 
once  instituted  the  most  active  measures  of  disinfection,  and  was  so  far 
successful  that,  although  eight  fatal  cases  followed  among  the  negroes 
occupying  that  hut,  the  disease  did  not  escape  to  the  city.  July  G,  a 
laborer  on  the  Cairo  and  Little  Rock  railroad  came  into  the  city,  went  to 
a  low  tavern,  where  he  was  taken  with  cholera  and  died  in  twelve  hours. 
This  case  was  successfully  isolated.  July  6,  a  convict  died  of  cholera  at 
the  State  penitentiary.  He  was  af  "trusty,"  and  for  several  days  before  his 
illness  had  been  working  on  steamboats  from  Memphis,  Tenn.  Three 
fatal  cases  followed,  with  many  cases  of  choleraic  diarrhoea.  The  disease 
was  again  stamped  out. 

That  the  city  of  Little  Rock  in  1873  was  not  ravaged  by  cholera  is  due  to 
the  energetic  action  of  Drs.  Thompson,  Dale,  Lenow  and  Carroll  in  stamp- 
ing out  the  disease  in  their  respective  cases,  and  the  exertions  of  the  health 
authorities  in  maintaining  the  city  in  good  sanitary  condition.  An  isolated 
group  in  a  house  epidemic  is  reported  by  Dr.  Liuthicum  as  occurring  at 
Helena.  In  a  family  of  seven  individuals,  six  died  in  three  days;  the 
eventh  made  a  lingering  recovery.  The  excreta  were  carefully  disinfected, 
and  the  hovel  in  which  the  cases  had  occurred  (after  the  removal  of  the 
seventh  case),  with  the  contents,  was  burned. 

The  first  recognized  case  of  cholera  at  Memphis,  Tenn.,  in  1873,  was 
on  April  15,  in  a  man  who  had  been  in  the  city  but  a  few  days,  having 
arrived  by  boat  from  the  lower  Mississippi.  He  died  in  a  filthy  boarding- 
house,  near  the  river,  after  an  illness  of  sixteen  hours.  The  second  case 
occurred  April  30.  in  a  man  who  kept  an  eating-stand  on  the  levee,  at  the 
point  where  two  railroad  lines  receive  and  discharge  freight.  This  was 
also  a  fatal  case,  and  it  occurred  in  the  adjoining  block  to  the  first  case. 
May  1,  a  section  boss  on  the  Memphis  and  Paducah  road,  then  in  process 
of  construction,  was  taken  with  cholera  and  died  May  3,  in  his  camp  at 
section  26,  on  the  line  of  the  railroad.  This  man  was  constantly  passing 
to  and  from  the  city,  and  his  business  carried  him  constantly  to  the  point 
where  the  second  case  occurred.  May  1,  cholera  occurred  in  a  railroad 
camp  at  section  19  of  the  same  road,  but  nearer  to  Memphis  by  seven  miles 
•than  the  camp  at  section  26.  In  a  day  or  two  cholera  also  appeared  in 
camp  on  the  same  road  at  section  21.  At  sections  19  and  21  convict 
laborers  were  employed;  at  section  26,  only  citizens.  The  drinking  water 
at  all  these  camps  was  very  bad,  the  surroundings  of  all  were  filthy. 

On  the  death  of  "  the  boss  "  at  section  26,  a  panic  occurred;  the  laborers 
scattered  in  all  directions,  the  majority  going  into  the  city  of  Memphis. 
The  convicts,  however,  at  camps  19  and  21  could  not  scatter;  the  disease 
spread  rapidly  among  them,  nearly  all  were  sick,  many  died,  but  it  was  not 
until  May  10  that  any  steps  were  taken  for  their  relief.  How  often 
cholera  had  been  brought  into  the  city  of  Memphis  before  and  succeeding 
the  events  from  April  15  to  May  10  which  have  been  narrated,  can  never  be 
learned.  The  city  was  in  a  shameful  sanitary  condition — there  was  virtually 
no  health  department.  The  mortuary  statistics  were  kept  by  undertakers 
alone.  Many  non-fatal  cases  may  have  occurred,  many  defined  cases 
may  have  arrived  among  the  lower  classes,  and  the  city  authorities  have 
been  none  the  Aviser.  It  is  probable  that  from  the  last  week  in  April  every 
steamer  from  the  lower  river  brought  to  Memphis  its  quota  of  infection. 


4g  ASIATIC  CHOLERA. 

It  is  positively  known  that  the  steamer  John  Kilgore  brought  to  Mempliis 
the  body  of  the  man  who  died  above  Vicksburg;  that  at  Memphis  this 
body  was  placed  in  a  casket,  and  that  it  was  forwarded  by  rail  from  ]Mem- 
phis  to  Cincinnati,  0.,  and  that  she  also  landed  two  cases  of  choleraic 
diarrhoea.  It  is  positively  known  that  no  attempt  at  disinfection  or  isola- 
tion had  been  attempted  on  the  Kilgore.  After  the  stampede  from  the 
cholera  camp  at  section  26,  cholera  rapidly  spread  over  Memphis.  The 
late  Dr.  J.  H,  Erskine,  a  distinguished  sanitarian,  who  had  great  expe- 
rience, describes  it  as  the  most  violent  he  had  ever  witnessed.  A  very 
marked  instance  of  the  diffusion  of  cholera  by  an  infected  well  occurred 
at  Lucy  station,  a  few  miles  out  of  the  ciijy. 

On  May  11,  a  gang  of  eighty  convicts  from  the  two  cholera  camps  at 
sections  19  and  21,  Memphis  and  Paducah  railroad,  arrived  at  the  State 
penitentiary  at  Nashville,  Tenn.  At  the  time  they  left  camp,  the  epi- 
demic had  not  subsided.  The  deputy  warden  in  command  was  so  ill  from 
cholera  that  he  could  not  accompany  them.  A  number  of  the  comrades 
of  these  men  had  died  of  cholera.  They  Avere  accompanied  by  four  Avomen 
convicts,  who  had  served  as  cooks  and  Avashwomen.  Every  member  of 
this  party  Avas  sick  with  diarrhoea,  having  copious  watery  stooh  accom- 
panied  in  very  many  cases  with  nausea  and  vomiting,  AA'hen  they  reached 
the  penitentiary.  The  four  women  were  dangerously  ill.  On  the  day  of 
the  convict  arrival  there  were  320  prisoners  in  the  institution,  of  whom 
but  tAventy  were  on  the  sick  report   for  ordinary  disorders. 

In  1873  all  the  penitentiary  drains,  from  privies,  urinals,  cesspools, 
Jcitdiens  and  Avash-houses  Avere  emptied  into  Avliat  is  knoAvn  as  the  Lick 
branch,  Avhich  floAVS  through  the  western  siiburbs  of  the  city  and  empties 
into  the  Cumberland  river.  The  laundry  and  female  deimrtment  are  in 
a  separate  inclosure  on  the  southeast.  The  drainage  from  this  portion 
of  the  penitentiary  was  for  100  feet  in  an  open  ditch  along  the  east  AA'all, 
when  it  entered  an  underground  sewer  and  was  by  that  conducted  to  the 
Lick  branch.  Upon  the  banks  of  the  Lick  branch,  as  it  flows  to  the  riA-er, 
Avere  many  wells  and  tAVO  springs  of  much  note  by  the  inhabitants — one 
''the  Judge's  spring''  the  other  appropriately  named  "the  sulphur  Avell.^' 
Tavo  days  after  the  arriA^al  of  the  gang  of  convicts,  one  of  their  number 
died  from  cholera,  and  although  the  disease  did  not  at  once  spread,  yet 
during  the  remainder  of  the  month  a  very  marked  increase  in  the  prison 
sick  report  was  obserA^ed.  *  May  20th,  a  negro  woman  living  on  the  line 
of  the  drain  from  the  female  department  Avas  taken  Avith  cholera,  but  she 
did  not  die  until  the  31st.  May  22,  a  man  Avho  lived  opposite  the  point 
of  exit  of  drain  from  the  female  department  died  of  cholera.  July  1,  a 
negro,  who  had  been  discharged  from  the  penitentiary  three  or  four  da3^s 
previously,  died  of  cholera  in  a  shanty  located  in  the  eastern  suburb  and 
quite  close  to  a  noted  spring,  the  AA^ater  supply  of  the  neighborhood, 
knoAvn  as  Wilson's  spring.  It  was  known  that  soon  after  the  return  of 
the  cholera-infected  convicts,  several  had  been  discharged  and  had  re- 
turned to  their  former  haunts  in  the  city.  By  their  influence  the  Avaters 
of  Bilbo,  Buck  and  Hackbury  springs  Avere  undoubtedly  polluted.  July 
8,  a  white  convict  in  the  penitentiary  died  of  cholera,  and  the  disease 
became  epidemic  within  its  walls.  A  frightful  epidemic  occurred  in  the 
city.  Dr.  W.  K.  BoAA'ling  collected  statistics  of  647  deaths,  but  it  is 
probable  that  the  true  number  of  fatal  cases  far  exceeded  those  figures, 

1  Narrative  Cholera  Epidemic  of  1873  in  the  U.  S.,  1875,  p.  149. 


THE  EPIDEMIC  IN  THE  UNITED  STATES  IN  1873.  49 

for  in  some  of  tlie  suburbs,  such  as  Rocktown  and  Xew  Bethel,  where 
the  mortality  was  very  great,  many  deaths  were  unreported,  the  burials, 
being  made  W  the  people  unaided  by  the  authorities. 

Cholera  was  carried  from  Xashville  to  Goodletsville,  Gallatin,  Shelby- 
ville,  Murfreesborough,  Lebanon,  Clarksyille,  Palmyra,  Farmington, 
Chattanooga,  GreenvQle  and  Union  City.  At  each  point  the  trail  of  epi- 
demic infection  Avas  very  clear.  Each  point  named  was  free  from  the 
disease  until  after  the  arrival  of  one  or  more  cholera-infected  individuals 
from  Xashville.  Each  point  to  which  cholera  was  carried  in  turn  trans- 
mitted the  disease  to  other  localities,  Knoxville  receiving  the  infection 
from  Chattanooga. 

The  epidemic  of  1873  in  the  State  of  Kentucky  opened  with  the  arrival 
of  the  steamer  John  Kilgore  at  Paducah,  May  18.  The  officers  of  the 
Kilgore  denied  that  cholera  had  been  on  the  boat,  and  during  the  stay  at 
Paducah  several  persons  of  the  town  spent  some  hours  on  her  decks  and  in 
her  cabins.  May  21,  a;  young  man  who  had  been  on  the  Kilgore  was  taken 
with  cholera  and  died  in  eight  hours.  May  23,  the  man  who  nursed  him 
also  died,  and  three  other  cases  of  those  who  had  contact  with  the  Kilgore 
followed,  when  that  group  of  infection  closed.  June  3,  a  woman  arrived 
at  her  home  in  Paducah  from  a  visit  to  Mempliis,  Tenn.  The  night  of 
her  arrival  she  was  taken  with  cholera  and  died  early  the  next  day.     July 

5,  a  Avoman  who  had  nursed  her  took  the  disease  and  died  in  48  hours. 
From  these  cases  the  epidemic  spread,  intensified  by  fresh  cholera  arrivals 
June  10,  on  steamer  Quickstej);  June  19,  on  steamer  Fish,  and  later  by 
every  steamboat  that  made  the  landing.  The  history  of  this  local  epi- 
demic is  full  of  instructive  instances  of  cholera  diffusions. 

At  Bowling  Green,  Ky.,  cholera  was  imported  from  Gallatin,  Tenn., 
June  3,  and  by  the  clothing  of  a  man  who  had  died  on  a  steam- 
boat after  leaving  Evansville,  Ind.,Junel3.  The  clothing  was  washed 
at  Bowling  Green  after  the  arrival  of  the  boat  by  a  negro  woman,  who 
died  of  cholera  within  thirty-six  hours  from  the  commencement  of  her 
task,  and  her  death  was  followed  by  86  cholera  cases,  with  65  deaths.  At 
Louisville,  from  June  8  to  August  16,  twenty-one  fatal  cases  occurred.  All 
were  in  persons  who  had  contracted  the  disease  in  some  cholera  center. 
That  no  epidemic  occurred  is  alone  due  to  the  sanitary  measures  which 
Avere  adopted  in  every  case.  Louisville  escaped  an  epidemic  of  cholera 
from  exactly  the  same  reason  that  afforded  immunity  to  Little  Eock, 
Ark.  That  Avas  the  vigilance  of  the  health  authorities  and  medical  prac- 
titioners. In  but  one  instance  was  there  any  sequence  of  cases.  A  family 
consisting  of  a  mother,  tAvo  single  daughters,  tAvo  married  daughters,  the 
husband  of  one  daughter  and  tAvo  grandchildren,  lived  in  a  small  house 
in  the  western  side  of  the  city.  Aug.  22,  Mrs.  G. ,  who  had  been  confined  tAvo 
Aveeks  previously,  Avent  to  Bowling  Green  to  visit  her  husband.  Aug.  25, 
she  Avas  taken  with  cholera  and  died.  Aug.  28,  her  body,  in  a  wooden 
coffin,  was  taken  to  her  mother's  house  in  Louisville  and  the  coffin  opened. 
Sept.  2,  a  child  was  taken  Avith  cholera,  but  recovered.  Sept.  4,  one  single^ 
daughter  died  of  cholera;  the  same  day  the  infant  of  first  case  died.     Sept. 

6,  the  married  sister  Avas  taken  and  died  Sept.  7;  the  remaining  daughter 
took  the  disease  but  recovered. 

Cholera  was  almost  universally  diffused  over  the  State  of  Kentucky;  very 
few  counties  escaped  the  disease.  A  careful  study  which  AA'as  made  dur- 
ing and  immediately  after  the  epidemic  shoAved  most  conclusively  that  the 
disease  was  carried  over  the  State  by  the  migi-ations  of  cholera-infected 


50  ASIATIC  CHOLERA. 

individuals.  I  shall  select  tlie  epidemic  as  it  occurred  in  but  three 
localities  for  the  present  study.  The  outbreak  of  the  disease  in 
Taylor  county  is  of  value,  for  in  it  is  found  the  first  link  in  a  most  virulent 
demonstration  of  the  disease.  A  negro  man,  who  had  been  working  in  a 
construction  party  on  the  Memphis  and  Paducah  E.  E.,  obtained  emjoloy- 
ment  on  the  Ohio  and  Cumberland  E.  E. ,  and  was  placed  in  a  gang  working 
on  the  tunnel  section  at  Muldrough's  Hill.  July  10,  he  was  taken  with 
cholera  and  died  in  one  of  a  group  of  negro  cabins  built  upon  a  hill- 
side, and  immediately  above  a  spring  from  which  all  the  neighborhood 
obtained  water.  The  dejecta  Avere  thrown  out  on  the  ground  around  this 
cabin.  On  July  14,  15,  and  16  there  were  heavy  rainfalls,  and  everything 
on  the  hillside  washed  down  into  the  spring,  nearly  filling  it  with  debris. 
July  IT,  a  severe  and  virulent  epidemic  followed  among  the  residents  of 
the  cluster  of  cabins. 

July  19,  a  negro  from  this  locality  (one  of  the  railroad  gang)  diea  of 
cholera  in  the  town  of  Lebanon.  The  death  occurred  in  a  shanty  on  the 
north  side  of  the  town  and  on  the  banks  of  a  small  stream  called  Jordan, 
which  flowing  through  low  ground  to  the  west,  forms  one  main  drain  of 
the  town.  The  cases  was  not  reported  and  no  disinfection  was  employed. 
Aug.  11,  a  negro  Avoman,  also  from  the  Taylor  county  focus  died  of  cholera 
in  a  cabin  on  the  banks  of  Jordan.  From  August  11  to  August  18, 
several  such  cases  occurred  among  negroes  living  in  the  same  locality,  all  of 
whom  died.  Aug.  18,  a  Avhite  man,  who  also  lived  in  the  same  locality, 
was  taken  ill,  but  recovered.  Aug.  19,  a  young  woman  living  in  the 
same  line  took  the  disease  but  recovered. 

None  of  these  cases  had  been  recognized  as  cholera,  in  none  Avere  dis- 
infectants employed.  The  excreta  of  all  Avere  emptied  into  or  on  the  sides 
of  the  Jordan,  then  almost  dry  and  choked  Avith  debris.  August  19,  a 
white  man  who  lived  upon  high  ground  at  some  distance  from  "Jordan,'' 
Avas  taken  Avith  cholera  and  died  after  a  five-hours'  illness.  It  was  found 
that  he  had  been  a  constant  visitor  of  a  woman  who  lived  in  the  infected 
locality.  In  this  case  the  excreta  Avere  disinfected  and  buried.  Aug.  25, 
a  third  case  from  the  infected  camp  in  Taylor  county  died.  Again  OA^ery 
precaution  AA'as  neglected.  It  Avas  impossible  to  aAvaken  any  public  inter- 
est in  these  cases.  The  physician  in  Avhose  hands  the  majority  occurred 
denied  that  they  Avere  cholera,  and  all  Avarnings  of  future  danger  Avere 
ridiculed. 

August  26  the  Marion  county  fair,  was  opened  on  the  grounds  near 
Lebanon.  All  Avater  used  on  these  grounds  Avas  carried  by  carts  from  the 
toAvn.  A  public  Avell  on  the  Avestern  side  of  the  toAvn,  near  the  railroad 
station,  and  on  the  banks  of  Jordan,  Avas  selected  to  furnish  the  neces- 
sary supply.  At  that  time  Jordan  Avas  no  longer  a  stream,  and  the  water 
in  the  Avell  was  limited.  August  27,  a  violent  rain-storm  occurred,  Jordan 
Avas  filled  to  overflowing,  all  the  debris  and  cholera  stuff  Avhicli  had  been 
accumulating  since  July  19  Avas  Avashed  doAvn  its  course  and  over  its  banks. 
The  toAvn  Avell  Avas  full  to  overfloAving.  During  August  28  and  29,  the 
attendance  upon  the  fair  Avas  very  large,  No  cases  of  violent  illness  had 
occurred  in  the  toAvn  since  August  25,  and  a  fatal  security  seemed  to  jjos- 
sess  all.  At  midnight  Aug.  29  the  bloAV  fell,  and  before  daylight  of 
Aug.  30,  thirteen  cases  of  cholera  had  occurred,  of  Avhom  tAvelve  died 
Avithin  the  next  ten  hours.  Each  individual  in  the  series  of  cases  had 
been  in  attendance  upon  the  fair.  All  had  drank  the  AA'ater  furnished. 
Age,  sex  or  social  condition  had  no  bearing  upon  the  cases.     At  almost 


THE  EPIDEMIC  IN  THE  UNITED  STATES  IN  1873.  5  J 

the  same  hour  at  which  this  Lebanon  epidemic  developed,  cholera  occurred 
in  the  country  for  miles  around;  wherever  individuals  lived  who  had  visited 
the  fair  grounds  and  had  drank  of  the  water,  cholera  occurred,  no  matter 
how  isolated  the  location  or  how  free  it  had  been  from  disease.  The  epi- 
demic lasted  to  Sept.  14,  but  isolated  cases  continued  to  occur  until 
October.  From  the  Marion  county  fair  grounds  cholera  was  carried  into 
Nelson  county,  where  several  malignant  house  epidemics  occurred;  to 
Columbia,  Adair  county,  where  a  malignant  house  epidemic  (Winfrey 
House)  occurred  in  the  first  instance,  which  spreading,  almost  depopulated 
the  town;  to  Washington  and  Boyle  counties  where  local  epidemics  fol- 
lowed. 

The  history  of  the  epidemic  in  Gerrard  county  is  very  instructive. 
Aug.  10, 1873,  a  man  named  Bewley  arrived  at  Lancaster  sick  with  a  pro- 
fuse diarrhoea,  from  Avliich  he  had  been  suffering  for  several  days.  He  had 
left  Eussellville,  Tenn.,  after  cholera  had  become  epidemic  at  that  town. 
He  had  made  the  journey  on  horseback.  On  his  arrival  he  was  lodged  by 
a  friend  who  lived  on  the  eastern  side  of  town,  upon  a  hillside,  at  the 
foot  of  which  was  a  public  well  from  which  many  people  obtained  water. 
The  day  after  his  arrival  cholera  developed,  but  he  did  not  die  until  Aug. 
22.  The  excreta  in  this  case  were  thrown  out  upon  the  ground  in  the  rear 
of  dirty  outhouses.  Aug.  14  a  negro  man  Avho  nursed  Bewley  was  taken 
Avith  cholera  and  died,  after  an  illness  of  eight  hours,  in  his  cabin,  near 
the  before-mentioned  well.  Aug.  15,  the  father-in-law  of  Bewley  who 
had  come  from  his  home,  ten  miles  from  town,  and  who  had  slept  the  pre- 
vious night  in  the  room  with  Bewley,  died  after  a  few  hours'  illness.  Aug. 
16,  a  negro  woman  who  lived  in  a  cabin  near  the  house  in  which  Bewley's 
nurse  died,  and  who  drank  the  water  from  this  well,  was  taken  with  cholera, 
and  died  after  twenty-two  hours'  illness.  Up  to  this  time  no  disinfectant 
had  been  used;  the  excreta  from  each  case  werescattered  broadcast  upon  the 
ground  around  the  dwellings.  Each  succeeding  day  fresh  cases  occurred, 
at  first  confined  to  those  who  drank  the  water  of  the  well  mentioned, 
but  the  disease  soon  spread  over  the  town.  The  epidemic  lasted  from 
Aug.  14  to  Sept.  5.  The  house  in  which  Bewley  died  had  been  closed, 
but  when  the  disease  disappeared  the  family  returned.  On  Sept.  20,  an 
old  lady  came  to  Lancaster  on  a  visit.  She  put  up  at  the  house  in  which 
Bewley  died  and  occupied  his  room.  She  slept  •  on  the  bed  one  night, 
when  she  was  taken  with  cholera  and  died.  At  Stanford,  Ky.,  a  malignant 
epidemic  was  occasioned  by  refugee  negroes  from  Lancaster. 

A  very  interesting  instance  in  support  of  the  theory  that  an  epidemic 
of  cholera  may  occur  whenever  the  specific  poison  of  the  disease  finds  a 
suitable  hotbed  for  its  propagation,  was  Clinton  county.  While  cholera 
was  epidemic  at  the  town  of  Columbia,  the  judge  and  commonwealth 
attorney  of  the  sixth  judicial  district  of  Kentucky  left  Columbia  for 
Albany,  Clinton  county.  They  had  been  in  Columbia  for  the  previous  two 
weeks,  had  lived  in  the  Winfrey  House,  and  the  night  before  they  started  on 
this  journey  had  nursed  a  friend  sick  with  cholera,  taking  turns  in  watching. 
A  few  miles  from  Columbia,  Mr.  Adair,  the  commonwealth  attorney,  com- 
plained of  malaise  and  nausea.  These  symptoms  became  more  severe  until 
5  o'clock  that  evening,  when  vomiting  and  diarrhoea  came  on;  he  was 
obliged  to  dismount  and  lie  upon  the  ground.  He  was  soon  after  carried 
to  the  house  of  a  man  named  Kelly,  which  was  not  far  distant,  where  he 
was  placed  in  bed  and  a  violent  attack  of  cholera  developed.  This  was 
on  August  31.     The  attack  was  typical,  and  although  Mr.  Adair  ultimately 


52  ASIATIC  CHOLERA. 

recoTcred,  his  convalescence  did  not  begin  nntil  .Sept.  10.  Mr.  Kelly's 
honse  was  located  high  np  on  one  of  the  spurs  of  the  Cumberland  moun- 
tains; so  isolated  that  the  owner  did  not  know  that  there  was  such  a  disease 
as  cholera  until  the  arrival  of  Mr.  Adair.  The  excreta  of  this  case  were  not 
disinfected,  but  were  thrown  into  the  privy  and  upon  the  ground  about 
the  house.  Mr.  Kelly,  his  daughter,  and  a  negro  servant  died  of  cholera; 
a  young  man  also  took  the  disease,  but  recovered.  These  cases  all  occurred 
while  Mr.  Adair  was  in  the  house  sick,  and  the  last  death  occurred  before 
he  was  pronounced  convalescent.  From  Columbia,  cholera  was  carried  to 
Jamestown,  Eussell  county,  where  two  severe  and  fatal  house  epidemics 
occurred. 

The  cholera  invasion  of  the  State  of  Illinois  dates  from  May  24,  when 
a  man  who  had  been  employed  as  a  bridge  builder  on  the  Memphis  and 
Paducah  railroad,  died  of  cholera,  in  Chicago.  No  other  cases  occurred 
in  that  city  until  June  10,  when  a  cholera  death  occurred  in  a  house  oc- 
cupied by  several  Danish  families,  and  in  which  an  emigrant  lately  arrived 
from  New  Orleans  had  been  sick  with  what  was  supposed  to  be  typhoid 
fever.  From  this  case  a  local  epidemic  occurred,  consisting  of  eight  cases, 
all  having  an  epidemic  connection,  and  from  them  a  circumscribed  epi- 
demic occurred  fed  by  occasional  importation.  That  no  serious  epidemic 
occurred  in  the  city  of  Chicago  was  due  to  the  activity  and  vigilance  of 
the  health  authorities. 

A  few  cases  occurred  at  Cairo,  111.,  June  15,  in  a  negro  from  New 
Orleans,  June  30,  in  a  man  from  Memphis,  who  was  found  drunk  on  the 
streets  and  lodged  in  the  jail,  when  cholera  developed;  he  was  discharged 
from  the  jail  and  died  in  hospital.  June  23,  the  wife  of  the  jailer,  Avhose 
room  was  immediately  above  the  cell  occupied  by  this  man,  was  taken 
with  cholera  and  died.  Three  other  local  cases  were  reported.  Disinfect- 
ants were  freely  used. 

At  Grand  Tower,  111.,  twenty-four  cholera  cases  were  reported,  with 
fifteen  deaths.  The  connection  of  the  first  cases  could  not  be  positively  de- 
termined, but  the  epidemic  influence  once  established,  the  spread  of  the 
disease  was  easily  traced;  and  the  same  statement  is  true  in  regard  to  cases 
which  occurred  in  Marion,  St.  Clair,  Jersey,  Scott,  and  a  few  other  coun- 
ties. At  White  Hall,  Greene  county,  the  epidemic  followed  the  arrival  of  a 
cholera  corpse  from  St.  Louis.  At  Carmi,  White  county,  the  first  case  oc- 
curred after  the  subject  had  returned  from  attending  the  funeral  of  a  cholera 
death  at  Evansville,  Ind.  At  OkaAvville,  Washington  county,  the  initial  case 
contracted  the  disease  at  St.  Louis,  Mo.  At  Rock  Island,  the  disease  was 
imported  from  Davenport,  Iowa.  At  Villa  Ridge,  one  case  was  taken 
from  a  Mississippi  river  steamer;  the  only  other  was  his  father-in-law.  In 
the  majority  of  these  instances  the  disease  was  confined  almost  exclusively 
to  house  epidemics;  in  Washington  county  alone  did  the  epidemic  spread 
through  the  community. 

It  was  a  matter  of  great  difficulty  to  obtain  reliable  facts  as  to  the  epi- 
demic of  1873  in  the  city  of  St.  Louis,  Mo.  Mr.  John  Moore,  the  most 
recent  investigator,  dismissed  that  epidemic  in  a  few  words:  "In  1873,  when 
cholera  appeared  again,  it  was  hardly  recognized  as  such,  and  the  victims 
as  counted  by  Doctor  M'Clellan  from  reports  of  local  physicians  numbered 
392."  The  absolute  truth  is  that  an  epidemic  of  cholera  did  occur  in  the 
southern  sections  of  that  city,  in  a  densely  crowded  population,  living  in 
tenement  houses  and  dirty  alleys,  where  all  the  disadvantages  of  deficient 
ventilation, defective  drainage,  and  bad  water  from  surface  wells  contributed 


THE  EPIDEMIC   IN   THE   UNITED   STATES   IN   1873.  53 

to  the  epidemic  diffusion.  The  first  case  in  the  city  (which  was  recognized) 
was  on  May  11th  in  a  man  who  had,  Just  before  his  attack,  returned  from 
Xew  Orleans.  This  case  was  fatal,  and  within  a  week  of  his  death  seven 
other  persons  who  lived  in  the  house  died  of  cholera.  From  this  center 
the  disease  spread,  and  from  it  cholera  was  carried  into  a  similar  neigh- 
borhood in  the  northern  limits  of  the  city  where  a  second  focus  was  estab- 
lished. The  health  officers  (at  that  time)  reported  that  392  cases  of  cholera 
deaths  had  occurred  with  137  deaths  from  cholera  morbus;  but  it  is  most 
probable  that  at  least  539  deaths  occurred  from  epidemic  cholera.  Dur- 
ing the  course  of  this  epidemic  many  interesting  cases  were  reported,  and 
the  efficacy  of  the  prompt  and  efficient  use  of  disinfectants  was  fully  de- 
monstrated. The  history  also  shows  that  the  Mississippi  river  steamers 
were  again  cholera-infected;  that  by  them  the  disease  w\as  brought  to 
the  city  of  St.  Louis  and  also  to  other  river  towns  of  Missouri.  From 
St.  Louis  cholera  was  carried  to  Jefferson  City,  the  State  capital.  The 
State  penitentiary  was  infected  by  a  gang  of  prisoners  employed  in  unloading 
a  Missouri  river  steamboat. 

The  epidemic  in  the  State  of  Indiana  opened  at  Mount  Vernon,  an 
Ohio  river  town.  The  steamboat  John  Kilgore  from  New  Orleans,  landed 
a  short  distance  above  the  town  on  May  20.  A  man  residing  near  the 
landing  who  had  been  on  the  Kilgore  during  her  stay  was  taken  with 
cholera  at  his  house,  died,  and  ten  cases  of  cholera  Avitli  eight  deaths  can  be 
traced  to  him.  A  citizen  of  Mount  Vernon  died  of  cholera  at  Nashville, 
Tenn. ;  his  brother  went  to  Nashville  and  returned  to  Mount  Vernon  with 
the  body.  The  coffin  was  opened  for  inspection.  Eight  cholera  cases  fol- 
lowed in  that  family.  From  May  26  to  June  21,  six  steamboats  from  either 
New  Orleans,  Memphis  or  Nashville  landed  at  Mount  Vernon,  all  having 
cholera  on  board.  In  addition,  the  Ohio  river  steamers  (all  cholera  infected) 
made  daily  visits  going  up  and  down  the  river.  June  2],  the  steamboat 
Camelia  landed  a  gang  of  negroes  from  Nashville;  one  of  these  negroes 
died  of  cholera  on  the  wharf -boat  soon  after  he  was  landed.  Other  cases 
occurred  rapidly  and  a  violently  persistent  epidemic  followed.  No  system- 
atic disinfection  was  attempted. 

The  city  of  Evansville  received  the  initial  importation  of  cholera  from 
the  steamer  John  Kilgore  on  her  trip  up  the  Ohio  river,  in  the  person  of 
a  deck  hand,  whom  she  left  in  the  stage  of  collapse.  Other  cases  were  sub- 
sequently left  by  other  steamers.  Strict  sanitary  measures  being  adopted, 
but  a  slight  epidemic  followed.  The  importation  of  cholera  into  Indian- 
apolis could  not  be  traced,  but  the  first  cases  occurred  opposite  to  the 
Union  passenger  railroad  station.  The  disease  was  confined  to  but  two 
houses.  A  German  woman,  who  had  been  in  one  of  the  Indianapolis  in- 
fected houses,  died  of  cholera  at  her  home  at  Cumberland,  ten  miles  east 
of  Indianapolis.  Her  funeral  was  largely  attended.  Five  days  later  fifteen 
cases  of  cholera,  eight  of  which  were  fatal,  occurred  among  those  who  had 
attended  the  funeral,  and  an  epidemic  followed  of  over  eighty  cases.  At 
Lawrence,  Ind.,  a  young  child  from  one  of  the  Indianapolis  infected 
houses,  died  of  cholera.  The  funeral  was  largely  attended  and  an  epidemic 
followed,  wdiich  was  prolonged  by  the  attendance  upon  subsequent  funerals 
of  cholera-patients,  forty-four  cholera  cases  with  twenty-four  deaths 
occurred.  These  last  two  instances  occurred  in  farming  communities 
where  friends  came  from  distances  to  attend  funerals,  eating  and  drinking 
at  the  house  of  mourning.  At  North  Vernon  and  Terre  Haute  a  fcAV  iso- 
lated cases  occurred.     At  Aurora,  a  man  from  Cincinnati  died  of  cholera. 


54  ASIATIC  CHOLERA. 

July  27.  His  dejecta  was  tlirown  out  on  the  ground  near  a  public  well. 
The  water  from  this  well  was  used  by  many  families,  and  fifteen  well- 
marked  cholera  cases  occurred  among  those  Avho  lived  within  a  radius  of 
four  hundred  yards  of  this  well. 

The  absolute  truth  of  the  importation  of  cholera  in  1873  into  the  State 
of  Ohio,  stripped  of  all  the  fallacious  arguments  at  the  time  employed  to 
conceal  it,  is  that  the  disease  was  imported  from  New  Orleans,  La. ,  hj  the 
steamer  John  Kilgore,  on  May  22;  the  steamer  Charles  Bodman.  May 
2-4;  the  steamer  H.  S.  Turner,  June  6;  the  steamer  C.  B.  Church,  June 
14;  and  the  steamer  Nicholas  Longworth,  June  23;  that  it  was  imported 
from  Memphis,  Tenn.,  by  the  steamers  Pat  Eodgers,  Arlington,  Mary 
Houston  and  James  D.  Parker ;  that  a  third  source  of  epidemic 
infection  were  the  steamboats  Eddyville  and  Camelia  from  Nashville, 
Tenn.  Each  of  the  boats  named  had  cases  of  cholera  and  choleraic  diar- 
rhoea on  board.  On  the  Parker  every  one  on  board  had  symptoms  of 
cholera  save  the  captain  and  clerk.  Later  in  the  season  all  the  steam- 
boats on  the  Ohio  river  became  cholera-infected  and,  by  all,  persons  and 
merchandize  which  had  been  exposed  to  the  specific  infection  were  landed 
in  the  city  of  Cincinnati, 

Cincinnati  being  the  home  station  of  most  of  the  steamers  on  the  Ohio 
and  lower  Mississippi  routes,  the  bed  linen  used  upon  them  is  usually 
Avashed  by  laundresses  on  shore.  On  the  Nashville  and  St.  Louis  boats, 
such  washing  is  generally  done  on  board  by  laundresses  from  the  shore, 
but  at  times  the  linen  is  taken  on  shore.  Dr.  Clendenin,  through  whose 
exertions,  the  light  of  truth  shines  on  this  local  epidemic,  states:  "  These 
facts  are  certainly  possessed  of  the  most  important  bearing  upon  the  his- 
tory of  the  introduction  of  the  disease,  and  from  them  the  diffusion  of 
cholera  over  the  city  of  Cincinnati  may  be  accounted  for." 

The  first  cholera  death  in  the  city  of  Cincinnati  occurred  at  the  city 
hospital  on  the  27th  of  May,  in  a  man  who  arrived  by  steamboat  from  some 
Kentucky  point  May  22.  "  The  day  before  he  was  admitted  he  was  taken 
with  diarrhoea,  cramps  in  his  legs  and  vomiting. "  This  case  lingered  until 
May  27,  when  he  died.  At  the  Cincinnati  hospital  the  excreta  of  all  patients 
was  placed  in  drains  Avhich  emptied  into  the  public  sewers;  disinfectants 
were  freely  used  and  the  drains  were  constantly  flushed  with  water.  In 
the  laundry,  superheated  steam  being  employed,  the  most  efficient  disin- 
fection of  fabrics  was  secured.  May  26,  a  child  died  of  cholera,  at  the 
home  of  its  parents,  which  was  at  the  point  of  the  river  bank,  east  of  the 
city,  where  steamboats  are  tied  up  when  not  making  regular  trips.  June 
6,  a  third  cholera  death  occurred  at  a  large  hotel  (the  Burnet  House),  in 
the  person  of  a  young  child  of  a  family  who  had  arrived  the  day  before 
from  fJie  South.  During  the  seasoii  207  cholera  deaths  were  reported  by 
the  health  office,  no  record  was  taken  of  non-fatal  cases,  and  diarrhoeal 
cases  w^ere  too  trivial  to  attract  notice.  The  disease  was  diffused  through 
the  districts  of  the  city  inhabited  by  the  poorer  classes.  It  was  an  epi- 
demic during  which  innumerable  foci  of  infection  were  established,  but 
which  were  promptly  stamped  out.  But  for  that  fact  the  disease  would 
have  been  as  malignant  in  Cincinnati  as  it  was  in  some  of  the  small  towns 
on  the  Ohio  river.  It  is  well  at  this  point  to  record  the  data  in  relation 
to  the  steamer  John  Kilgore.  This  steamer  left  New  Orleans,  La.,  May 
13  (during  the  month  of  May  125  cholera  deaths  were  reported  in  New 
Orleans. )  She  had  a  large  list  of  passengers,  many  of  whom  were  on  deck, 
and  most  of  whom  were  flatboatmen,  from  different  places  on  the  Mis- 


THE  EPIDEMIC  IN  THE  UNITED  STATES  IN  1873.  55 

sissippi  and  Ohio  rivers.  The  day  after  leaving  Xew  Orleans,  a  Mr. 
Schenck  of  Cincinnati,  a  cabin  passenger,  was  taken  with  cholera;  when 
the  Kilgore  reached  Vicksbnrg,  Mr.  Schenck  was  still  alive  and  the  ser- 
vices of  Dr.  Booth  were  obtained.  Mr.  S.  died  at  a  point  abont  50  miles 
above  Vicksburg,  and  his  body  was  carried  to  Memphis.  The  excreta  of 
this  case  was  not  disinfected,  nor  was  any  care  taken  Avitli  the  clothing, 
bed  or  bedding.  On  reaching  Memphis,  a  casket  was  obtained  for  the 
body,  which  was  then  forwarded  by  rail  to  Cincinnati.  Two  passengers 
went  ashore  at  Memphis  with  choleraic  diarrhoea.  At  Paducah,  Ky.,  an 
epidemic  occurred  from  contact  with  this  boat.  After  leaving  Paducah, 
three  deck  joassengers  died  from  cholera;  one  was  buried  near  Shawnee- 
town,  one  near  Rome,  and  one  above  Evansville,  all  on  the  Ohio.  Her 
arrival  was  the  first  cause  of  the  violent  epidemic  at  Mount  Vernon;  and 
had  not  the  health  authorities  of  Louisville  been  active  and  vigilant  she 
would  have  infected  that  city,  for  there  she  landed  the  greater  portion  of 
her  deck  passengers. 

At  Carthage,  ten  miles  north  of  Cincinnati,  a  most  interesting  illus- 
tration of  the  portability  of  cholera  occurred.  A  man  named  Tenthave, 
his  wife,  five  children,  a  sister  of  the  wife,  and  two  young  men,  arrived 
in  Xew  York  on  the  steamship  City  of  Limerick  from  Liverpool  on  July 
5,  1873.  They  left  Xew  York  City  July  6th  for  Carthage,  Ohio,  via  the 
Baltimore  and  Ohio  Railroad.  On  July  10th  they  arrived  at  Cincinnati, 
too  late  to  proceed  that  day  on  their  journey,  and  the  entire  party  spent 
the  night  in  a  station-house.  Early  the  next  day  they  left  Cincinnati  for 
Carthage.  July  13th  the  boxes  and  bales  of  household  property  arriving, 
the  entire  party  took  possession  of  a  small  house.  Everything  was  un- 
packed for  use;  the  bedding  and  clothing  had  not  been  touched  before 
since  they  were  packed  up  at  Tubbergen,  Holland.  July  15th  a  child  was 
taken  ill  with  cholera;  a  few  hours  later  the  father  and  a  second  child  took 
the  disease.  July  16th  the  mother  sickened;  July  ITth  a  third  child  had  the 
disease;  July  19th,  a  fourth  child;  July  ^^d,  the' fifth  child;  July  •23d.  the 
young  woman  was  attacked.  These  cases  all  terminated  fatally  in  from  eight 
to  twenty-four  hours.  The  two  young  men  suffered  severely  from  diarrhoea, 
but  recovered.  Living  in  the  rear  of  this  infected  house,  some  one  hun- 
dred yards  distant,  was  a  young  married  woman,  pregnant  with  her  first 
child.  Forbidden  by  her  husband  to  go  near  the  Tenthave  house,  she  each 
day  provided  some  articles  of  food  which  she  placed  on  the  fence  in  the 
rear  of  the  cholera  house.  Each  day  she  received  the  utensils  in  which 
this  food  had  been  served.  July  23d  she  was  taken  with  cholera  and  died 
after  forty-eight  hours'  illness,  aborting  twenty  hours  before  death. 
By  Doctor  Bunker,  who  had  charge  of  these  cases,  disinfectants  were  em- 
ployed, and  the  disease  did  not  spread  in  the  town  of  Carthage.  On  the 
21st  of  July,  however,  cholera  suddenly  developed  in  the  negro  wards 
of  Longv'iew  insane  asylum.  This  institution  is  located  on  the  southern 
ide  of  Carthage.  The  negi'o  wards  are  in  a  detached  building  at  some 
distance  from  the  main  institution.  It  was  supposed  that  a  perfect  svstem 
of  non-intercourse  had  been  preserved,  but  the  investigations  of  Dr.  Clen- 
denin  proved  clearly  that  such  was  not  the  case.  Joseph  Marshall,  a 
negro,  the  supervisor  of  the  attendants  in  the  negro  wards,  impelled  by 
curiosity,  went  frequently  to  the  infected  house.  After  the  last  death  in 
the  Tenthave  family,  the  man  Marshall  appropriated  to  his  own  use  a 
braided  shooting-coat  which  had  belonged  to  Tenthave.  He  carried  the 
coat  to  the  as3'lumj  and,  as  he  found  it  wet,  hung  it  up  on  the  back  porch 


56  ASIATIC  CHOLERA. 

to  dry.  Wliile  in  this  position  it  attracted  the  attention  of  a  patient, 
who  took  it  down,  wore  it  for  the  remainder  of  the  day  and  slept  in  it  that 
night,,  when  it  was  again  taken  possession  of  by  ]\Iarshall.  The  next  day 
the  patient  who  had  worn  the  coat  and  four  other  patients  were  taken  with 
cholera;  when  Marslmll,  properly  connecting  the  outln'eak  with  the  stolen 
coat,  burned  it  at  the  kitchen  fire.  From  this  importation  thirteen  cases 
of  cholera,  with  nine  deaths,  occurred. 

At  Dayton,  Ohio,  the  ei)idemic  was  confined  to  but  two  houses.  At 
several  other  points  isolated  cases  occurred,  but  which,  with  two  excep- 
tions, are  traced  back  to  the  house  epidemic.  The  only  direct  im])ortation 
which  could  be  traced  was  a  man  from  Memphis,  Tenn.,  who  died  in  a 
hotel.  His  case,  however,  was  disconnected  with  those  that  followed. 
Da}i;on,  however,  is  a  great  railroad  center,  and  to  the  efficiency  of  rail- 
roads as  common  carriers  of  infection  as  well  as  merchandize  must  be 
ascribed  the  occurrence  of  the  disease  at  Dayton,  Springfield  and  Colum- 
bus, Ohio.  At  the  last-named  city  the  initial  case  occurred  in  the  person 
of  a  woman  who  kept  a  low  grog-shop  under  the  bridge  of  the  Pittsburgh, 
Cincinnati  and  8t.  Louis  Railroad  as  it  leaves  the  city.  The  position  is 
such  that  a  cholera  dejection  or  a  choleraic  diarrhoea  discharged  at  that 
point  would  inevitably  fall  at  the  back  door  of  that  house. '  Xot  only 
did  the  initial  case  occur  at  that  point,  but  the  majority  of  the  early  cases 
were  in  its  immediate  vicinity.  After  the  epidemic  had  gained  full  head- 
way in  the  city,  that  was  the  most  virulently  infected  district.  Cholera  was 
carried  within  the  State  penitentiary  walls  by  guards,  teamsters  and  night 
watchmen  who  lived  in  the  infected  locality.  Of  twenty-seven  cases  which 
occurred  in  the  penitentiaiy,  twenty-one  were  fatal. 

It  was  impossible  to  trace  any  direct  connection  between  the  early  cases 
at  Wheeling,  West  Virginia,  and  any  well-defined  focus  of  cholera  infec- 
tion. They,  however,  occurred  in  localities  which  from  their  filthy  con- 
dition were  most  favorable  for  the  reproduction  of  the  disease.  The 
epidemic  having  obtained  a  foothold,  many  instances  of  the  diffusion  of  the 
disease  were  found.  The  earliest  cases  were  on  June  9tli  and  20th.  Doc- 
tor S.  L.  Jepso]!  states  that  the  steamers  Andes  and  E.  R.  Hudson,  the 
weekly  packets  between  Cincinnati  and  Wheeling  during  the  months  of 
June  and  Jxily,  brought  many  sick  with  profuse  diarrhoea  from  the  former 
to  the  latter  city. 

At  Pittsburgh,  Penn.,  07i  July  29th,  a  man  and  his  wife  returned  to 
their  home  after  a  visit  to  Cadiz  Junction,  Ohio.  August  1st  the  wife  was 
taken  with  cholera  and  died  August  4th.  The  day  of  his  wife's  death 
the  man  was  seized  and  died.  Aug.  Gtli  a  woman  who  had  nursed  these 
cases  was  taken  with  cholera  and  died.  The  most  active  sanitary  jJrecau- 
tions  were  adopted.  Clothing,  bedding  and  carpets  were  burned.  Aug. 
8th,  a  man  who  had  been  employed  to  destroy  this  property  was  taken 
with  cholera  and  died  Aug.  10th.  No  spread  of  the  disease  occurred. 
The  husband  of  the  first  case  informed  his  physician  that  while  he  was 
at  Cadiz  Junction  cholera  was  epidemic  among  railroad  employees. 

Three  well-defined  points  of  cholera  infection  occurred  in  the  State  of 
Alabama.  In  anticipation  of  cholera  infection,  the  city  of  Huntsville  was 
placed  in  as  good  sanitary  condition  as  was  possible.  No  connection  with 
the  epidemic  as  it  existed  at  either  Memphis  or  Nashville,  Tenn.,  could 
be  found,  except  that  the  early  cases  occurred  on  low  ground,  along  the 

'  While  in  railroad  stations  it  is  customary  to  keep  the  closets  in  cai-s  locked 
and  not  to  open  them  until  the  station  is  left. 


THE  EPIDEMIC  IN  THE  UNITED  STATES  IN   1873.  57 

line  of  the  railroad  and  about  100  yards  from  tlie  station.  The  epidemic, 
however,  once  started,  the  disease  was  carried  wherever  individuals  who 
had  been  exjDosed  to  the  infection  resided.  It  was  carried  to  Monte  Sauo, 
a  mountain  watering-place,  and  to  Johnson's  Wells.  At  Birmingham, 
June  12tli,  a  man  who  had  been  in  the  city  for  six  weeks,  and  who  Avas  in 
perfect  health,  was  taken  with  cholera  and  died  after  a  day's  illness. 
Three  days  before  this  attack  he  had  received  his  bedding  from  Hunts- 
ville,  and  had  used  it  up  to  the  time  of  his  death.  June  ITth  a  case  of 
cholera  occurred  in  a  family  Avho  had  constantly  been  with  the  first  case, 
and  before  the  close  of  that  day  there  was  another  case  in  the  same  family; 
both  died.  Xo  disinfectants  were  used  in  either  of  these  three  cases.  The 
discharges  of  all  were  thrown  into  a  small  almost  dry  *"  Ijranch  ''  which  ran 
through  low  marshy  ground,  from  which  many  people  obtained  their 
drinking  water.  June  19th  a  man  who  had  just  returned  from  Chatta- 
nooga, where  he  had  been  for  several  weeks,  died  of  cholera  after  eighteen 
hours'  illness.    From  these  cases  the  epidemic  spread  in  most  virulent  form. 

From  Birmingham  cholera  was  carried  to  the  city  of  Montgomery  by 
a  negro  man  who  had  been  employed  as  a  cholera  nurse;  no  epidemic 
followed.     The  city  was  blessed  with  a  most  efficient  health  officer. 

In  but  two  instances  could  cases  of  cholera  be  discovered  in  the  State  of 
Georgia.  Both  were  in  the  persons  of  refugees  from  the  disease  at  Chat- 
tanooga. One  case  was  at  Atlanta,  the  other  at  Dalton;  both  terminated 
fatally  both  were  carefully  isolated  and  disinfected.  Xo  other  cases  followed. 

At  Crow  river,  Kandiyohi  Co.,  Minn.,  occurred  an  interesting  group 
of  cases  in  the  family  of  Swedes  named  Antonson.  This  family  arrived 
at  Xew  York  on  the  steamer  Peter  Japson,  June  26,  18T3.  From  Xew 
York  city  this  family  were  transported  to  St.  Paul,  Minn.,  via  Pittsburgh, 
Penn.,  Grand  Haven  and  Milwaukee.  They  rested  twenty-four  hours 
at  St.  Paul,  when  they  started  for  Crow  Eiver,  via  WiTlmar,  Minn.  They 
arrived  at  Crow  Eiver  July  2d.  Before  leaving  Bergen,  Sweden,  the 
effects  of  this  family  were  packed,  except  hand  baggage.  AVhen  they 
arrived  at  Willmar,  Minn.,  their  property  was  unpacked  for  additional 
articles  of  clothing,  and  the  next  day  Antonson  sickened  with  cholera, 
but  he  did  not  die  until  July  10th.  July  6th  a  son  Avas  attacked  and  died 
in  forty-eight  hours;  July  9th  a  daughter  Avas  taken  and  died  jn  tAventy 
hours;  July  12th  another  daughter  died  after  ten  hours'  illness,  and  the 
same  day  the  man  at  Avhose  house  in  CroAV  River  they  had  stopped  died 
of  cholera  eight  hours  after  he  was  attacked.  Tavo  other  non-fatal  cases 
occurred.  The  recital  of  this  group  of  cases  greatly  disturbed  Petten- 
kofer,  Avho  endeavored  by  ridicule  to  bring  discredit  upon  it.  But  in 
spite  of  all  subsoil  Avater  theories,  the  case  stands,  and  after  a  lapse  of  ten 
years  I  have  no  hesitation  in  bringing  it  forAvard  again. 

At  Davenport,  loAva,  an  epidemic  of  eighty-nine  cases  of  cholera,  with 
forty-three  deaths,  folloAved  the  arriA'al  of  cholera  cases  on  a  steamboat 
from  St.  Louis,  Mo.,  on  August  14th. 

At  Kelton,  Utah,  a  house  epidemic  occurred  Aug.  ISth  in  a  family 
recently  arrived  from  Missouri. 

At  Yankton,  Dakota,  a  virulent  epidemic  of  cholera  occurred  among 
Eussian  emigrants,  and  at  a  Eussian  colony  a  few  miles  distant;  a  few 
cases  of  cholera  occurred  in  the  city  of  Yankton,  but  no  diffusion  of  the 
disease  occurred.  Among  the  Eussians  the  epidemic  closely  folloAved  the 
arriA'al  of  a  large  party  who  had  recently  arrived  from  the  Odessa  district. 

During  1873  cholera  Avas  repeatedly  brought  into  Xew  York  harbor, 
but  in  no  instance  did  it  escape  the  quarantine  grounds. 


58  ASLITIC  CHOLERA. 


CHAPTER  IX. 

CHOLERA  IN  BOMBAY,  ESPECIALLY  IN  1883. 

Almost  all  the  interest  in  cholera  from  India  now  centers  upon  Bom- 
bay. Thns  Bombay  is  connected  Avith  Calcutta.  Madras  and  Allahabad  by 
railroad,  and  can  get  cholera  from  them;  but  it  also  has  pestilences  of  its 
own  every  year.  Cholera  has  prevailed  in  Bombay  city  and  its  Presidency 
every  year  since  1848,  and  almost  every  month  in  the  year.  The  most  dan- 
gerous months  are  March,  April,  ^May  and  June,  perhaps  also  July;  then 
the  cases  fall  off  rajoidly  in  August,  September,  October  and  November, 
to  increase  twofold  in  December,  January,  February  and  March.  In 
June  the  great  southwest  monsoons  or  rain  storms  come  on  and  flood  out 
the  disease. 

It  is  encouraging  that  cholera  is  generally  far  less  prevalent  in  Bombay 
than  in  olden  times;  since  the  great  ei^idemic  of  1865  the  deaths  have 
scarcely  ever  reached  an  average  of  1,000  per  year  for  the  whole  city, 
only  in  1877,  Avhen  they  counted  up  2,510;  in  1878,  1,165;  in  1883,  1,914. 

In  1883  the  epidemic  commenced  in  May  with  84  deaths;  in  June 
there  were  84;  July,  231;  August,  429;  Sej^tember,  152;  and  then  they 
fell  off  rapidly  with  only  24  deaths  in  October,  4  in  Xovember.  37  in 
December,  only  2  in  January,  1  each  in  February  and  March,  and  15  in 
April. 

The  cholera  of  1883  in  'Egypt,  probably  derived  from  Bombay,  com- 
menced in  May  and  died  out  in  midsummer,  aided  by  the  great  drought, 
which  is  just  as  destructive  to  cholera  germs  as  excessive  rains.  The  great 
rise  of  the  Xile  also  flooded  out  the  pestilence.  The  cholera  of  Toulon, 
Marseilles,  France,  Italy,  Genoa  and  ISTaples,  Spain  and  Algiers,  died 
out  unusually  early  in  the  fall. 

The  great  cholera  months  in  Calcutta  are  February,  March,  April  and 
May;  out  of  25,000  deaths,  there  may  be  12,000  to  16,000  deaths  in  May, 
but  there  will  be  only  half  that  number  in  June,  and  only  one-third 
in  July,  August  and  September.  But  they  will  double  up  in  October, 
November,  December  and  January.  The  February,  March,  April  and 
Mav  Calcutta  germ  may  be  more  hardy  and  last  over  winter  in  Europe 
and  America. 

The  Bombay  Presidency  covers  124,000  square  miles;  the  jDopulation  is 
16,000,000.  The  year  1883  was  an  unhealthy  one,  as  there  was  not  only  a 
wide-spread  epidemic  of  cholera,  but  much  small-pox,  while  fevers  Avere 
in  excess  and  locusts  abounded.  There  was  unusually  heavy  rain  with  the 
southwest  monsoon  in  June,  while  the  easterly  rains  in  September  and  Octo- 
ber were  more  abundant  and  prolonged  than  usual.  There  were  500,000 
births  and  420,000  deaths.     Among  the  3,000,000  Mohammedans  there 


CHOLERA  MORTALITY  IN  BOMBAY. 


59 


were  57,000  deaths;  of  the  13,000,000  Hindoos  there  were  355,000  deaths; 
of  140,000  Christians,  3,700  deaths;  of  the  80,000  other  castes,  outcasts 
and  pariahs,  4,000  deaths. 


CHOLERA  MORTAIJTY  BY  MONTHS  FOR  THIRTY- 

FTTE  YEARS  IX  BOMBA\ 

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1857  459 

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1883  1014 

"  In  1883,  in  January,  the  pestilence  had  nearly  died  ovxt,  as  only  28  deaths 
were  recorded  throughout  the  whole  Presidency.  In  February,  it  had  almost  en- 
tirely disappeared,  as  only  one  doubtful  case  was  repoi-ted.  In  March,  too,  only 
18  deaths  occuri^ed;  but  in  April,  the  disease  suddenly  assumed  an  epidemic  form, 
as  936  deaths  were  recorded.  In  May  a  still  further  and  very  great  increase  took 
place,  as  5.622  deaths  were  reported.  In  June,  9,447  deaths  occurred,  and  in  July 
the  mortality  rose  to  the  very  serious  amount  of  12,708 — the  maximum  for  the 
year.  In  Aug-ust  the  pestilence  began  to  abate  rapidly,  as  only  6,733  deaths  were 
reported,  and  in  September  the  death  rate  fell  to  1,230,  and  in  October  to  mei-ely 
695.  A  fui'ther  decrease  was  observed  in  November,  as  only  340  deaths  were 
counted,  and  in  December  the  pestilence  had  declined  to  146  for  that  month. 


go  ASIATIC  CHOLERA. 

"In  the  Presidency,  out  of  37,954  cholera  deaths  in  1883, 19,587  occurred  among 
males,  and  18,097  among-  females. 

'  In  Bombay  city  with  a  population  of  773,196,  in  1883  there  were  1,400  at- 
tacks, 613  in  males,  403  in  females;  the  rest  were  children.  The  percentage  of 
deaths  to  attacks  was  69  per  cent. 

"In  the  military  cantonments,  with  a  population  of  51,573  persons,  there  were 
45  deaths;  so  that  they  wovild  not  convey  much  disease  to  Europe  on  tlie  fme  P. 
&  O.  steamships. 

"Out  of  the  34,536  villages  m  the  Presidency,  3,199  were  attacked,  or  13  per 
cent.  In  Kandeish  out  of  2,679  villages,  764,  or  28  per  cent. ,  were  attacked.  In 
Ahmednuggur,  just  east  of  Bombaj',  out  of  1,331  villages,  633,  or  46  per  cent.,  were 
involved.  In  Poonah,  just  below  Bombay,  471  villages  out  of  1,181,  or  40  per  cent. 
In  Nassick,  just  north  of  Bombay,  343  villages  out  of  1,639,  or  21  per  cent.  In 
Holopur,  southeast  of  Bombay,  207  villages  out  of  709,  or  38  per  cent." 

The  outbreak  commenced  March  15,  1883,  at  Nassick,  northwest 
of  Bombay,  where  there  are  great  and  beautiful  temples;  next  at  Ahmed- 
nuggur  to  the  east,  April  9tli.    At  Bombay  city  it  was  rather  later. 


CHOLEEA  IN  EGYPT  IN  1883.  Ql 


CHAPTER  X. 

CHOLERA  IN  EGYPT  IN  1883. 

Ix  June,  18S3,  cholera  was  suddenly  announced  at  Damietta  on  one 
of  the  mouths  of  the  Nile  nearest  Port  Said,  the  outlet  of  the  Suez  canal. 
Damietta  has  about  35,000  inhabitants,  and  in  addition  15,000  more  people 
came  to  a  great  yearly  fair.  A  mixed  commission  of  eleven  English, 
French,  Italian  and  Eg}"ptian  physicians  was  sent  from  Alexandria,  and 
on  June  25th  reported  the  disease  to  be  cholera;  and  from  the  rapid 
spread  of  the  pestilence,  the  number  of  nearly  sudden  deaths,  the  great 
number  of  persons  attacked,  the  large  portion  of  fatal  cases,  the  area  over 
which  the  disease  had  already  spread  beyond  the  city,  they  declared  it  to 
be  epidemic  cholera.  At  this  late  date  they  were  unable  to  decide 
Avhether  it  arose  locally  or  was  imported.  They  decided  that  the  great 
outbreak  commenced  on  June  19th  with  six  deaths,  which  is  impossible, 
for  there  must  have  been  previous  cases.  The  health  officer  had  only 
noticed  the  disease  on  June  2'2d  and  23d,  when  there  were  14  and  23 
deaths,  which  he  thought  rather  much  for  a  beginning.  The  town  is 
traversed  by  a  canal,  Avliich  receives  the  contents  of  the  drains  of  the 
mosques  and  houses  on  its  banks,  yet  is  used  for  drinking  water  by  part  of 
the  people:  hence  there  seemed  to  be  no  infection  from  one  case  to  another, 
but  only  numerous  cases  from  the  drinking  water;  and  partly  from  the 
unwholesome  gases  and  effluvia  from  the  latrines  and  drains,  especially 
those  of  the  mosques  which  were  so  largely  visited  by  the  fair  people.  The 
flesh  of  animals  dead  of  bovine  typhus  was  said  to  have  been  sold  in  large 
cjuantities.  A  great  many  dead  cattle  floated  down  the  river  and  lodged 
near  the  town;  many  stale  salt  fish  were  also  used  for  food.  Hence  the 
localists  made  out  a  good  case  at  first. 

July  14th,  or  more  than  a  month  after  the  outbreak,  Surgeon-General 
Hunter  was  sent  from  England  to  examine  into  the  origin  of  this  ej)idemic 
as  its  nature  as  Asiatic  cholera  was  already  admitted. 

The  British  consul  also  adopted  the  local  theory,  and  put  the  origin 
of  the  disease  on  the  bad  sanitary  condition  of  the  town,  the  bad  meat  used, 
the  impure  water,  and  the  overcrowding  of  people  at  the  festival.  He 
says  it  could  not  have  been  imported,  as  the  nearest  place  where  it  pre- 
vailed was  Bombay,  and  there  he  was  erroneously  assured  it  was  not  epi- 
demic. But  there  had  been  84  deaths  in  Bombay  city  in  June,  and  before 
the  year  ended  there  were  37,954  in  the  whole  i:>rovince.  He  was  on  the 
Egyptian  Sanitary  Council,  and  takes  pride  in  saying  that  he  had  fought 
many  a  battle  with  his  colleagues  in  the  interest  of  British  shipowners 
and  the  vast  English  commerce  in  the  East. 

All  the  15,000  fair  and  festival  people  were  driven  out  of  Damietta 


Q2  ASIATIC  CHOLEEA. 

and  10,000  of  tlie  inhabitants  allowed  to  go  witli  them;  and  then  a  cordon 
of  400  soldiers  was  put  around  the  town  and  no  one  allowed  to  go  in  or 
out;  even  provisions  and  medicines  were  stopped  so  that  the  rest  were 
almost  starved.  But  the  pestilence  was  already  scattered  broadcast  over 
Egvpt.  The  outbreak  was  so  sudden  that  contaminated  water  could  only 
have  been  the  cause.  On  June  20th  there  were  only  4  deaths;  June  21st 
only  1;  June  22d,  14;  23d,  23;  24th,  42,  and  15  more  were  suspected  to  be 
cholera;  25th,  42,  and  32  suspects;  26th,  47,  with  37  suspects;  27th,  129; 
2Sth,  106.     All  Avas  in  doubt  and  suspicion  till  the  27th. 

The  markets,  slaughter-houses  and  public  privies  were  supervised;  fresh 
fish,  vegetables  and  fruit  were  seized ;  stale  fish,  hides,  bones  and  rags  were 
all  placed  in  special  warehouses.  The  latrines  of  the  mosques,  prisons,  bar- 
racks, schools  and  all  public  places  were  disinfected,  and  the  houses  of  the 
sick  also.  Eags  and  soiled  clothes  were  burned;  cholera  hospitals  were 
established  in  other  cities,  in  advance.  The  house  and  street  drains 
emptying  into  the  canal  were  closed  and  quicklime  thrown  into  them  and 
it.  The  people  were  driven  out  of  their  houses  into  tents  and  sheds.  In- 
side the  cordon,  the  houses  were  cleansed  and  the  worst  hovels  demolished. 
These  measures  had  apparently  arrested  the  epidemic  of  1865,  Avhich  was 
the  last  Egyjit  had  had;  i.e.  there  had  been  no  cholera  for  twenty  years 
in  Egypt,  notwithstanding  all  its  filth  and  fairs. 

The  sanitary  doctor  of  Port  Said  came  and  said  the  symptoms  were 
very  marked  and  decisive,  and  were  undoubtedly  those  of  Asiatic  cholera, 
and  that  the  disease  must  have  been  imported.  As  late  as  July  7th,  Dr. 
Mackie  said  no  real  attempt  had  been  made  to  arrive  at  its  origin  or  cause. 
It  was  established  that  the  bovine  tA'phus  prevailed  first:  that  many  dead 
animals  were  thrown  into  the  Nile,  and  the  people  were  drinking  this  foul 
water.  There  was  a  sudden  access  of  hot  weather,  which  was  excessive; 
the  dampness  and  the  uncleanliness  of  Damietta,  like  that  of  every  Egyp- 
tian town,  were  abominable,  yet  only  Damietta  was  attacked  at  first,  and 
the  other  towns  only  after  refugees  had  come  to  them.  Port  Said  and 
Tantah,  which  had  another  horrible  fair  and  festival,  were  the  second 
places  attacked. 

Alexandria  escaped  for  a  comparatively  long  time,  although  it  had  a 
vile  system  of  sewers,  and  house  drains,  with  open  latrines  for  servants  in 
the  very  center  of  the  kitchens.  The  sewers  had  never  been  cleaned  and 
could  not  be  cleaned,  and  they  were  neither  trapped  nor  ventilated,  nor 
yet  the  house  connections  upon  them. 

Eour  Bombay  merchants  and  a  fireman  of  the  Bombay  steamship 
Timor  were  now  charged  with  bringing  cholera  to  Damietta,  but  could 
not  be  found.  All  the  cases  in  Alexandria  (78)  up  to  June  30th  had  been 
at  the  Damietta  fair,  or  came  from  two  steamships,  the  Kate  and  St.  Ber- 
nard, which  came  from  Bombay  on  June  30th  with  cases  on  board. 

A  large  number  of  refugees  Avent  to  Mansourah,  without  money  or 
food,  but  as  the  wind  was  northwest,  cholera  was  supposed  to  have  been 
bloAvn  by  it  from  Damietta;  but  the  northeast  part  of  the  town  Avas  first 
attacked;  fruit  and  vegetables  were  entirely  prohibited,  and  the  place  AA'as 
cleansed  as  Avell  as  possible,  while  fires  Avere  lighted  in  all  the  streets.  The 
nationality,  age  and  hour  of  death  of  the  first  67  cases  were  collected, 
but  no  mention  is  made  of  Avhere  they  came  from.  Food  and  medicines 
were  dropped  at  the  cordon,  miles  aAvay,  and  no  means  provided  to  get 
them,  as  the  railroads  stopped  running.  Then  the  most  deaths  Avere 
found  to  be  in  the  center  of  the  tOAvn,  Avhere  the  narroAV  streets  prevented 


CHOLERA  IN  EGYPT  IN  1883.  (33 

the  northwest  wind  from  coming,  and  where  there  was  ver}'  little  ventila- 
tion or  wind  at  all ;  400  dead  cattle  were  taken  out  of  the"  river.  It  was 
found  that  the  oordon  was  daily  evaded  by  the  natives,  large  numbers 
of  whom  had  left  the  town,  and  the  disease  was  traveling  southward. 
Many  Greeks  and  Syrians  also  escaped,  and  went  down  to  Cairo  and  up 
to  Alexandria.  The  houses  even  of  the  notables  were  found  in  a  most 
disgraceful  state  of  filth,  and  some  of  the  owners  were  fined  or  imprisoned : 
diarrhoea  became  common  but  not  very  fatal.  The  air  was  very  hazv,  and 
cholera  was  supposed  to  dwell  in  it.  Many  cases  died  in  a  few  hours' Avith- 
out  previous  diarrhoea  or  vomiting.  A  great  many  soldiers  forming  the 
cordon  were  attacked ;  the  sentinels  stationed  in  the  cemetery  were  seized. 

Dr.  Mackie  said  the  study  of  the  outbreak  epidemiologically,  commer- 
cially and  politically  was  of  the  most  intense  interest;  and  the  investiga- 
tors would  have  to  be  very  independent  men,  entirely  free  from  all  polit- 
ical influence  if  the  truth  was  to  be  arrived  at.  Scarcely  a  case  of  true 
cholera  had  occurred  in  Eg^^jt  since  1866.  Young  doctors  and  disinfect- 
ants were  sent  to  Mansourah,  but  to  disinfect  an  Egyptian  town  so  as  to 
stop  cholera  was  like  pouring  a  bucketful  of  water  into  the  sea  to  float  a 
stranded  vessel.  To  disinfect  such  towns,  they  should  be  destroyed  by  fire. 
The  only  hope  Avas  in  the  rising  of  the  Xile.  As  soon  as  cases  occurred 
in  a  village,  the  inhabitants  fled  to  prevent  being  shut  in  by  a  cordon ;  eight 
doctors  and  forty-four  hospital  assistants  were  sent  from  India.  From 
July  11th  to  17th.  4:28  died  in  Mansourah,  and  their  bodies  were  buried  in 
shallow  brick  tombs  only  fifty  to  sixty  centimetres  deep;  and  no  earth  or 
quicklime  was  used.  People  began  to  seize  each  other's  tombs,  and  then 
the  owners  would  come,  drag  out  the  strange  bodies,  and  leave  them  on 
the  open  ground.  The  corpses  of  the  best  people  Avere  washed,  wrapped 
in  a  new  sheet  with  camphor,  and  carried  to  the  tombs  in  public  coffins 
and  then  put  without  a  coffin  in  the  shallow  and  cracked  brick  tombs, 
from  Avhich  bad  smells  and  gases  of  decomposition  arose.  The  public 
coffins  were  then  purified.  Calm  hot  days  increased  the  mortality;  fresh 
Avinds  even  from  the  northwest  lessened  it.  There  was  an  almost  mi- 
raculous coincidence  in  the  rapid  decrease  of  the  epidemic  with  the  first 
rising  of  the  waters  of  the  Xile.  There  Avere  many  large  inclosures  filled 
Avith  ruins,  and  great  heaps  of  refuse.  Dry  clean  sand  was  spread  over 
the  streets.  The  latrines  of  the  mosques  and  public  baths  were  nailed  up; 
but  the  sewers  emptied  into  the  river,  and  many  Avells  were  filled  with 
f-xcal  matter.  Interments  generally  took  place  in  the  midst  of  the  towns. 
In  less  than  one  month  there  Avere  exactly  1,999  deaths  (thev  could  not 
make  it  2,000  without  lying)  from  cholera  in  Damietta,  of  Avliich  1,998  were 
Egyptians;  1,952  Avere  poor,  only  47  rich;  1,698  died  in  the  city,  301  in 
the  suburbs;  997  were  males,  513  of  whom  Avere  children,  1,002  were 
females,  among  them  414  children;  only  10  were  foreigners. 

The  Port  Said  cases  are  said  to  have  commenced  June  23d,  and  to 
have  been  brought  from  Damietta,  which  only  acknowledged  the  disease 
on  the  22d.  Dr.  Flood  sent  all  the  cases  to  hospital,  emptied,  disinfected, 
and  whitewashed  the  infected  houses,  locked  them  up  for  twelve  days,  and 
thus  stamped  out  the  disease  at  Port  Said.  He  Avas  familiar  with  cholera, 
and  unhesitatinglv  pronounced  it  Asiatic.  The  Avind  Avas  drv  and  cool, 
24°  to  29°  Cent. 

The  typhoid  stage  of  cholera  was  mistaken  for  typhoid  fever  and  the 
disease  pronounced  by  others  as  malarious,  or  else  coming  from  the  cattle 
plagues.     In  a  large  lodging-house  in  Alexandria  an  old  lady  was  taken 


(34  ASIATIC  CHOLERA. 

with  cholera  and  all  the  inmates  fled,  not  from  fear  of  the  disease,  for  they 
offered  to  stay  and  nnrse  her  provided  they  would  not  be  sent  up  and 
quarantined  for  an  indefinite  time. 

Surgeon-General  Hunter  only  commenced  his  investigations  into  the 
origin  of  the  epidemic  on  Aug.  8,  1883.  Cholera  arrived  at  Cairo  July 
15th,  brought  there  by  refugees  who  fled  from  Menzaleh  before  the  cordon 
was  formed.  The  city  was  filthy;  the  dead  were  covered  with  shawls,  which 
were  afterward  worn  by  the  relatives.  There  were  7G4  deaths  the  first 
week,  2,438  the  second  week,  which  was  heavier  than  in  1865,  when  there 
were  only  205  and  1,919.  Boulak  and  old  Cairo  suffered  most  severely. 
The  peojale  lived  in  mud  hovels,  eight  feet  by  eight  feet  and  only 
six  feet  high,  with  five,  six  and  seven  persons  in  each;  together 
with  sheep,  poultry,  and  small  cattle.  The  natives  are  low,  dirty, 
and  even  filthy.  The  temperature  was  from  28.7°  to  30.7°  Centi- 
grade; barometer  755  to  753;  hygrometer  38.35  to  46.76.  The  pre- 
vailing winds  were  from  northeast  to  north.  They  were  west  in 
1865.  The  vice-consul  said  the  sparrows  did  not  fly  away  but  chirped 
merrily  all  during  the  cholera;  the  flies  and  mosquitoes  stayed  also. 
The  sky  Avas  azure,  pure  and  light;  there  was  no  heavy  lead  or  any 
other  grim  colored  atmospliere.  The  disease  was  not  in  the  air  but  in 
the  people  and  their  filth,  and  in  the  water.  Cairo  has  367,000  inhabi- 
tants. 

August  6,  1883,  Shibin  el  Kom,  with  16,000  inhabitants  had  had  1,000 
deaths  from  cholera.  Damanhair  Tantah,  Zagazig  and  Eosetta  were 
attacked  later.  The  epidemic  followed  the  east  branch  of  the  aSTile  from 
Damietta;  it  was  only  recently  that  the  western  or  Ivosetta  branch  was 
involved.  Alexandria  as  yet  had  escaped  with  a  few  isolated  cases;  but 
villages  on  the  ]\rahmoudieli  canal,  which  supplies  it  with  water,  were  now 
attacked.  Ghizeli,  two  miles  from  Cairo,  had  800  deaths.  It  was  re- 
markable how  little  the  rest  of  Cairo,  except  Boulak  and  old  Cairo,  had 
been  affected.  They  are  on  the  river  Nile,  and  lost  24  to  30  per  thousand; 
the  rest  of  the  city  only  8. 73  per  thousand.  The  six  quarters  of  Cairo  far- 
thest from  the  river  only  had  20  deaths  a  day,  out  of  163,844  inhabitants. 
The  Nile  water  was  evidently  at  fault. 

Eleven  more  villages  had  from  10  to  20  deaths  each;  31  more  from  1  to 
7  each.  Uii  to  August  8th,  Cairo  had  lost  5,249.  The  tombs,  or  brick 
shells,  were  opened  again  and  again  for  fresh  corpses.  The  burying  was 
as  bad  as  could  be,  scarcely  two  feet  under  ground.  At  Mansourah  fifteen 
or  tAventy  bodies  were  often  lying  on  the  ground,  waiting  burial  and  rela- 
tives and  many  friends  standing  around.  There  were  over  2,000  refugees 
in  the  town,  and  the  shops  Avere  out  of  provisions. 

Alexandria  gets  her  drinking  Avater  from  the  Eosetta  Nile  at  Asfeh, 
thence  through  the  Mahmoudieh  canal,  21,000  tons  daily;  population 
210,000.  Alum  iron  was  used  to  purify  this  Avater.  The  bombardment 
of  the  town  had  left  many  open  spaces,  and  freer  ventilation ;  the  scAverage 
was  pumped  out  into  the  bay.  By  Aug.  6th  there  had  been  16,117  deaths 
in  Egypt.  In  Damietta  most  of  the  hut  dAvellings  Avere  underground  cellars, 
like  mere  cesspools;  or  Avere  huts  made  of  straAV,  mud  Avith  coAV-dung  for 
mortar.     Fish  and  rice  Avere  the  general  food. 

Much  Avater  Avas  kept  in  cisterns,  filled  from  the  Nile  when  in  high 
water.  There  Avere  cemeteries  all  around  the  toAvn  like  a  belt;  the  streets 
Avere  defiled  Avitli  ftecal  filth.  Cholera  broke  out  in  the  most  croAvded 
and  unhealthy  part  of  Damietta  suddenly  on  June  22;  the  mouth  of  the 


CHOLERA  IN  EGYPT  IN  1883.  Q^ 

river  was  dried  up  by  a  long  drought.  Thousands  of  carcasses  of  animals 
lodged  on  the  banks  and  the  drains  emptied  there;  there  was  miasma- 
from  the  rice  fields.  This  water  was  used  by  15,000  strangers,  who  went 
into  veritable  orgies.  The  epidemic  broke  out  just  at  the  end  of  the 
fair,,  when  great  heat  set  in.  The  water  contained  putrescent  matter  and 
vibrios. 

Surgeon-General  Hunter  reviewed  the  whole  ground,  and  says  the 
tombs  were  hollow  brick  structures  6  feet  by  4,  with  a  hole  at  one 
end  to  push  in  the  bodies — when  full  they  were  bricked  up.  The  village 
barber  is  the  first  register  of  vital  statistics;  he  shaves  the  corpse  and  takes 
down  what  the  relatives  tell  him  was  the  cause  of  death,  and  then  he  grants 
a  burial  permit. 

Egjrpt  has  only  had  five  epidemics  of  cholera,  viz.,  in  1848, 1850, 1855, 
1865  and  1883,  Filth  diarrhoea  is  common  and  fatal;  but  only  one  or 
tAVO  cases  a  year  of  cholera-morbus  or  cholerine  occur.  A  boy,  aged  5, 
died  of  cholera  at  Damietta  on  June  19th.  Another  case  happened  as 
early  as  May.  Two  Greek  children  also  died  on  April  27th.  A  barber 
died  of  cholera  at  the  end  of  April.  One  case  of  cholera  was  drummed  up 
in  1867,  and  another  in  1873.  There  Avere  one  or  tAvo  cases  only  of  cholera 
morbus  every  year;  rarely  more.  A  tobacco  seller  died  May  13th.  In 
1881, 1,889  died  of  dysentery  in  Cairo;  1,097  of  gastric  and  typhoid  fcA^er. 
In  1882,  1,993  died  of  dysentery  and  1,472  of  gastric  and  typhoid  fever. 
The  cholera  came  practically  to  an  end  on  Sept.  11th.  The  outbreaks  in 
1865  and  1883  both  took  place  at  Karmoose,  the  most  unhealthy  part  of 
Alexandria. 

Surgeon  McXally  showed  that  diarrhoea  and  vomiting  had  prcA'ailed 
at  Zagazig  ever  since  January,  1883,  and  had  been  fatal  to  200  persons: 
that  great  mortality  had  been  at  Chibin  el  Kom  prior  to  the  report  of  the 
cholera  at  Damietta;  also  in  villages  near  Benha,  Avith  more  than  fifteen 
deaths  a  day.  Chevalier  said  cholera  had  been  in  Upper  Egypt  six  years 
before. 

At  Mahallet  el  Kebeen  cholera  was  not  reported  till  July  lOth,  but 
numerous  cases  occurred  before  that  date;  diarrhoea  was  common  and 
intractable;  on  one  day  twenty-nine  died  of  cholera. 

Another  says  cholera  alAA'ays  folloAvs  cattle  plague. 

Dr.  Hunter  thinks  it  has  been  endemic  in  Egypt  since  1865,  because  a 
few  cases  of  cholera  morbus  occur  each  year. 

Dr.  Mahe  thought  cholera  Avas  introduced  by  coalers  and  stokers  on 
steamships  running  betAveen  Bombay  and  Port  Said. 

Dr.  Hunter  also  makes  the  extraordinary  statement  that  cholera  has 
never  been  imported  from  India  to  Egypt  or  Europe  !  !  or  any  other  coun- 
try, and  adds,  in  no  case  can  cholera  be  proved  to  have  been  imported  from 
India;  and  in  cA'ery  alleged  instance  of  importation  the  allegation  has  failed 
to  bear  examination.  He  says  there  Avere  only  192  deaths  from  cholera  in 
Bombay  in  1882,  against  529  in  1881,  and  120  from  the  first  six  months, 
of  1883. 

LcAvis  and  Cunningham  found  a  rapid  development  and  multiplication 
of  bio-plastic  bodies  in  the  blood,  but  could  not  ino^alate  animals  Avith 
fresh  excreta  nor  AA'ith  those  22  days  old,  and  no  other  person  can;  the 
one  is  too  fresh  and  the  other  too  stale. 

All  the  early  records  in  Damietta  Avere  lost  by  the  death  of  the  principal 
barber  who  acted  as  the  registrar  of  vital  statistics. 
5 


gg  ASIATIC  CHOLERA. 

Dr.  S.  v.  DeCastro  concludes  from  his  study  of  the  cholera  in  Egypt  in  1883  ' 
that  the  disease  was  most  probably  imported  from  India.  He  says  that  while 
this  cannot  be  proven  witli  certainty,  it  is  much  more  probable  than  all  the  other 
hypotheses  put  together  which  have  been  advanced  as  to  the  origin  of  that  epi- 
demic. He  thinks  that  hygiene  of  cities,  houses  a-nd  individuals  is  the  most  effec- 
tive means  in  our  power  to  prevent  the  spread  of  cholera.  e.  c.  w. 

1  Cholera  in  Egitto  nel  1883,  sua  Origine  e  Misure  igieiiiclie  e  quaranteuarie.    Milan,  1884. 


CHOLERA  IN  FRANCE  AND  ITALY  IN  1884.  QJ 


CHAPTER  XL 

CHOLERA  IN  FRiVNCE,  ITALY  AND  SPAIN  IN  1883  AND  1884. 

It  was  generally  supposed  that  no  cholera  escaped  from  Egypt  into 
Europe,  but  that  all  was  carried  back  by  refugees  from  Damietta  south 
into  EgyjDt  toward  Arabia,  Damietta  has  so  little  commerce  with  Europe 
that  this  was  to  be  expected;  although  the  shipping  from  Alexandria  is 
very  much  less  than  before  the  opening  of  the  Suez  canal  in  1869,  still 
there  was  much  more  danger  from  it,  especially  to  France.  We  now  know 
that  there  was  a  small  epidemic  at  Marseilles  in  1883,  which  was  carefully 
concealed;  the  doctors  and  nurses  having  been  sworn  to  secrecy  by  the 
authorities.  Where  this  cholera  came  from  is  not  yet  positively  known, 
whether  from  Tonquin,  China  or  Egypt,  as  the  particulars  are  still  pur- 
posely shrouded  in  darkness. 

The  first  we  heard  of  cholera  in  France  for  a  long  time  was  at  Toulon 
early  in  June.  Transports  from  Tonquin  with  the  disease  arrived,  and 
its  presence  was  concealed  for  at  least  three  weeks,  until  it  could  be  hid- 
den no  longer.  Then  all  the  early  records  were  not  only  lost,  but  shame- 
fully concealed.  The  consequence  was  the  tremendous  panic  with  which 
all  are  familiar.  At  least  10,000  or  15,000  Italian  laborers  fled  from  Tou- 
lon, some  to  Marseilles  and  many  more  to  their  homes  in  Italy.  The  epi- 
demic broke  out  in  Marseilles  so  soon  after  it  Avas  announced  at  Toulon, 
that  some  doubt  has  been  raised  whether  there  was  a  recrudescence  from 
the  fall  epidemic,  or  whether  it  was  brought  from  Toulon.  The  earliest 
cases  seemed  to  be  in  refugees  from  Toulon;  but  no  one  knows  whether 
still  earlier  cases  were  concealed  until  the  blame  could  all  be  put  on  Tou- 
lon. Cholera  had  been  so  prevalent  in  the  French  army  and  fleet  at 
Tonquin,  that  their  operations  were  seriously  interfered  with,  and  of  course 
the  French  authorities  concealed  all  they  could  about  it  for  political  and 
military  reasons.  But  infected  transports  did  come  to  Toulon.  The  same 
panic  arose  in  Marseilles,  and  at  least  10,000  or  15,000  more  Italians  fled 
to  Italy. 

In  the  lower  part  of  Toulon  the  water  supply  is  scanty  and  bad,  and 
much  runs  from  the  fountains  in  the  ujjper  part  into  the  gutters  in  the 
lower  part  and  down  to  the  harbor,  which  is  land-locked,  almost  tideless, 
and  so  very  foul  that  tyjjlioid  fever  prevails  largely  at  almost  all  times. 
The  lower  Toulonese  also  have  no  privies,  but  empty  their  chamber-pots 
into  the  streets  and  gutters  every  morning,  and  throw  out  all  their  garbage 
there  also.  The  market  people  were  seen  freshening  their  vegetables  by 
dipping  them  in  the  gutter  water. 

The  water  supply  of  Marseilles  is  abundant  and  good,  but  the  gutter 
water  from  numberless  fountains  was  used  as  in  Toulon.      Not  much 


gg  ASIATIC  CHOLERA, 

cholera  was  carried  north,  but  a  few  scattering  cases  occurred  in  Paris 
every  month.  Still  as  they  did  not  at  once  reach  the  water  supplies  there 
was  no  extended  outbreak  until  September,  and  even  then  the  deaths 
scarcely  reached  1,000.  It  was  stopped  more  by  the  advent  of  cold  weather 
than  by  any  other  cause. 

The  quarantine  on  the  northern  border  of  Spain  was  so  severe  that  little 
pestilence  got  over  the  boundaries.  But  a  family  from  Marseilles,  wish- 
ing to  escape  quarantine,  went  down  to  Algiers,  where  there  was  no  cholera 
yet,  and  sailed  for  Alicante  on  the  east  coast  of  Spain  and  started  an  epi- 
demic there. 

The  Italian  refugees  from  France  slipped  through  the  mountain  passes 
and  brought  the  pestilence  to  the  most  western  provinces  of  Italy,  viz. 
Turin  and  Cuneo.  The  Italian  government  sent  transports  to  carry  off 
others,  which  were  landed  principally  at  Genoa,  Massa  Carrara,  further 
down  the  Avest  coast,  and  especially  at  Naples.  No  less  than  three  great 
importations  took  place  at  Naples.  At  Genoa  cholera  discharges  are 
known  to  have  got  into  the  water  supply.  At  Naples,  in  addition  to  the 
horrible  filth  of  the  affected  parts,  surface  wells  were  largely  in  use,  and 
only  too  often  became  contaminated  from  the  pozzis  or  privies  with  which 
each  house  was  supplied,  and  which  when  full  overflow  into  the  street 
gutters.  The  general  water  supply  of  Naples  is  scanty  and  bad.  Rome 
refused  to  receive  any  refugees  and  escaped  pestilence.  Ultimately  it 
came  out  that  almost  every  really  malarious  city  and  province  in  Italy 
escaped  cholera,  while  many  of  the  non-malarious  towns  were  heavily  at- 
tacked. I  first  drew  attention  to  this  fact  by  examining  the  large  official 
map  of  the  malarious  districts  of  Italy. 

The  epidemic  cost  France  and  Italy  40,000  or  50,000  lives  and  many 
hundreds  of  millions  of  money.  The  loss  of  the  latter  is  still  going  on, 
and  .will  go  on  until  it  is  proven  that  there  will  be  no  recrudescence  of  the 
pestilence  this  summer.  The  travelers  to  Italy  and  France  have  been  few 
this  winter,  and  will  be  far  fewer  this  whole  year. 

Scattered  cases  occurred  in  Paris  until  the  suburb  of  Aubervillier, 
in  the  extreme  northeast,  was  involved,  and  cholera  discharges  got  into 
the  canal  St.  Denis,  which  empties  into  the  canal  de  L'Ourcq.  Dr.  Eoux 
calculates  that  one-fourth  part  of  all  the  fcecal  matter  of  Paris  is  swept 
down  the  river  Seine  to  the  north,  beside  that  which  is  carried  to  the 
great  poudrette  works.  In  all  the  great  epidemics  in  Paris  the  heaviest 
stress  of  the  pestilence  has  fallen  upon  the  districts  supplied  with  river 
Seine  water  and  that  from  the  canal  L'Ourcq,  which  is  distributed  without 
filtering  for  drinking  and  cooking  water.  Of  course  contagion  or  infec- 
tion from  case  to  case  could  rarely  be  proved,  except  in  hospitals  and 
asylums  where  it  was  manifest.  The  disease  was  attributed  to  miasma; 
but  the  air  had  to  traverse  the  whole  southern  and  central  parts  of  Paris, 
which  it  did  without  causing  cholera,  in  order  to  reach  the  northern  ar- 
rondissements,  where  cholera  finally  broke  out  after  a  few  cases  got  there 
and  contaminated  the  water. 


SECTIO]Sr    II. 


A  HISTORY    OF    EPIDE3IIC    CHOLERA,  AS    IT 
AFFECTED  THE  ARMY  OF  THE  UNITED  STATES. 


BY 

ELY    McCLELLAX,    M.D., 

MAJOR  A>'D   SURGEON  U.    S.    ARMY. 


THE  EPIDEJvHC  IN  THE  UNITED  STATES  AKMY  IN  1833.         7^ 


CHAPTER  XII. 

GENEEAL  REMARKS  AND  THE  EPIDEMIC  OF  1832  TO  1835. 

General  Remarks. — Ten  years  ago,  iu  a  history  of  the  cholera  epi- 
demic of  1873  in  the  United  States,  I  formulated  the  exjierience  which  was 
attainable  from  that  epidemic,  in  a,  series  of  propositions  which,  although 
they  excited  a  storm  of  adverse  criticism  have  survived  the  lapse  of  a  dec- 
ade to  be  strikingly  verified  by  the  experimental  research  of  Koch  and 
other  obseiTers. 

It  has  been  shown  that  cholera  is  constantly  diifused  over  extensive 
areas  of  territory  by  the  movements  of  individuals  ;  that  troops  and  camp- 
followers  have  at  times  been  active  agents  in  such  diffusion.  It  is  a  well- 
established  fact  that  cholera  being  epidemic  in  a  country  occupied .  by 
troops,  the  disease  almost  inevitably  appears  among  them,  and  that  by 
their  movements  the  epidemic  area  is  extended. 

The  history  of  cholera  outbreaks  among  troops  and  the  agency  which 
troops  have  exerted  in  its  diffusion  in  times  past,  is  of  value  as  indicating 
not  only  what  may  be  expected  in  future  ej)idemics,  l)ut  what  sanitary 
precautions  should  be  adopted  by  wliich  a  repetition  of  such  histories  may 
be  prevented  ;  for  the  history  which  will  hereafter  be  presented  fully 
demonstrates  the  fact  that  epidemic  cholera  will  develop  at  any  locality  to 
which  the  specific  poison  of  the  disease  may  be  carried,  and  in  which  it 
finds  a  suitable  hot-bed  for  its  prolification. 

The  Epidemic  of  1832  to  1835  amoxg  Troops. 

In  the  spring  and  early  summer  months  of  1832  a  series  of  military 
movements  commenced  against  the  Sac  and  Fox  Indians,  who  were  led  by 
Black  Hawk;  and  an  army  composed  of  troops  serving  along  the  Missis- 
sippi frontier,  the  Atlantic  coast,  and  Western  volunteers,  was  ordered  to 
the  field.  On  the  first  day  of  July  seven  companies  of  infantry  destined 
for  this  campaign  Avere  embarked  on  the  steamer  Henry  Clay  at  the  city 
of  Buffalo,  Xew  York  State.  The  Henry  Clay,  prior  to  her  being  char- 
tered as  an  army  transport,  had  been  engaged  in  the  emigrant  service. 
By  adverse  winds  the  boat  with  her  living  cargo  was  detained  at  Buffalo 
until  the  morning  of  July  3d,  when  she  sailed  for  Detroit.  July  4th, 
cholera  broke  out  among  the  troops,  and  before  she  arrived  on  July  5th, 
two  cholera  deaths  had  occurred.  When  the  Henry  Clay  arrived  in  the 
Detroit  river,  the  steamer  Sheldon  Thompson  had  but  a  short  time  pre- 
ceded her,  having  on  board  General  Scott  and  staff,  six  companies  of  ar- 
tillery and    two  of  infantry  troops.     The  garrison  of  Fort  Xiagara,  con- 


72  ASIATIC  CHOLERA. 

sisting  of  78  men,  had  arrived  at  Detroit  on  the  30th  of  June,  and  were 
quartered  in  an  old  brick  building  on  the  banks  of  the  river,  in  the  most 
filthy  part  of  the  town.  They  had  been  conveyed  from  Buffalo,  N.  Y.,  to 
Detroit  by  steamboat. 

The  disease  spread  with  frightful  rapidity  on  the  Henry  Clay,  and  on 
July  7th  the  troops  were  landed  one  mile  below  Fort  Gratiot  on  the  St. 
Clair  river.  Two  days  later  it  is  reported  that  owing  to  the  virulence  of 
the  epidemic,  by  deaths  and  desertions  among  the  panic-stricken,  the 
seven  companies  which  had  left  Buffalo  but  five  days  before  were  reduced 
to  a  total  of  but  sixty-eight  (68)  men.  A  large  number  of  deserters  from 
the  camp  are  reported  to  have  died  from  cholera  in  the  surrounding 
country,  many  on  the  roadside.  July  8th,  cholera  appeared  among  the 
troops  from  Fort  Niagara;  the  same  day  two  men  who  had  been  employed 
to  communicate  with  the  steamer  Henry  Clay  died  of  the  disease  in  the 
city  of  Detroit,  and  the  authorities  of  that  city  having  become  alarmed, 
demanded  the  removal  of  the  troops,  who  were  accordingly  ordered  to  the 
camp  below  Fort  Gratiot.  The  steamboat  Sheldon  Thompson  being  free 
from  the  disease,  on  the  Gth  of  July  proceeded  on  the  journey  and  arrived 
at  Fort  Mackinaw.  On  the  evening  of  the  7th,  cholera  having  developed 
among  the  troops  on  the  voyage,  four  cases  were  sent  to  hospital.  All 
proved  fatal,  July  8th,  no  other  cases  of  cholera  occurring,  the  Thompson 
proceeded  on  her  voyage;  the  next  day  twenty-one  (21)  cases  of  cholera 
occurred,  and  when  on  the  night  of  July  10th  she  reached  Chicago,  there 
had  been  a  total  of  seventy-six  (7G)  cases  and  nineteen  (19)  deaths. 

By  order  of  General  Scott  the  uninfected  garrison  of  Fort  Dearborn 
was  marched  into  camp  some  two  miles  distant.  The  fort  was  converted 
into  a  cholera  hospital.  x\t  Fort  Dearborn  the  disease  was,  if  possible, 
more  virulent  than  it  was  at  the  camp  near  Fort  Gratiot;  it  spread  in  the 
(then)  village  of  Chicago,  and  was  carried  into  the  camp  of  hitherto  un- 
infected troops  (garrison  of  Fort  Dearborn)  the  first  cases  therein  being  in 
the  persons  of  soldiers  who  in  direct  violation  of  orders  had  visited  Fort 
Dearborn.  The  senior  medical  officer  reported  that  previous  to  the  arrival 
of  the  Sheldon  Thompson  ''  there  was  not  a  case  of  disease  of  any  kind  at 
the  fort  or  village."  ' 

Throughout  the  month  of  July  the  disease  continued,  and  so  disastrous 
were  its  consequences  that  the  general  commanding  the  army  (Macomb) 
states  in  that  portion  of  his  report  which  relates  to  the  Black  Hawk  War: 
"  Unfortunately,  however,  the  cholera  was  just  at  this  time  making  its 
way  into  the  United  States  from  Canada,  and  infected  our  troops  while  on 
board  the  steamship  in  their  passage  up  the  lakes,  and  such  was  the  ra- 
pidity with  which  the  disease  spread  among  them,  that  in  a  few  days  the 
whole  force  sent  by  the  lakes  was  rendered  incapable  of  taking  the  field. 
Some  were  landed  at  Fort  Gratiot,  others  were  stopped  at  Detroit,  while 
the  principal  part  reached  Chicago  in  a  most  deplorable  condition."  ^ 

On  the  1st  of  August,  the  officer  commanding  at  Chicago  reported 
that  the  disease  was  subsiding;  that  no  deaths  had  occurred  in  the  last 


'  The  medical  officer  reported  "at  the  time  it  was  generally  believed  that  the 
principle  of  infection  existed  in  tlie  steamboat  in  which  the  troops  were  conveyed 
from  Buffalo  to  Detroit,  the  vessel  liaving  been  employed  in  transporting  crowds 
of  filthy  emigTants  westward  from  Montreal  and  Quebec.  The  Henry  Clay, 
among  the  troops  on  board  of  whicli  the  disease  also  appeared,  had  been  engaged 
in  the  same  kind  of  service." — Medical  Statistics  U.  S.  Army,  1840,  p.  91. 

2  Medical  History  of  the  Army,  1840,  p.  81. 


THE  EPIDEMIC  IN  THE  UNITED  STATES  ARMY  IN  1832.         73 

sixty  hours,  and  that  very  few  new  cases  liad  occurred.  The  remnant  of 
the  troops  from  Fort  Gratiot  and  numl)ers  of  deserters  from  that  camp 
reached  Chicago  in  the  early  days  of  August.  By  the  13th  of  August 
cholera  had  disappeared  from  among  the  troops  camped  at  Chicago,  and 
the  march  for  Rock  Island  was  commenced. 

At  Chicago,  the  northwest  spread  of  the  epidemic  would  have  been 
undoubtedly  arrested  had  the  wise  orders  of  General  Scott  been  obeyed; 
but,  as  if  to  demonstrate  early  in  the  first  American  epidemic  the  agency 
of  individuals  in  the  diffusion  of  cholera,  a  most  flagrant  disobedience  of 
orders  occurred,  and  as  a  result  another  body  of  troops  were  infected,  the 
disaster  of  Chicago  was  reenacted  at  Rock  Island,  and  epidemic  cholera 
was  spread  over  a  great  area  of  country. 

The  violence  of  the  epidemic  subsiding,  on  the  29th  of  July  General 
Scott  left  Chicago  and  crossed  the  country  to  Prairie  du  Chien,  on  the  Mis- 
sissippi, where  he  met  Brigadier-General  Atkinson,  with  the  troops  under 
his  command,  returning  from  the  Bad  Axe  River,  where  he  had  routed  the 
Indians  under  Black  Hawk  on  the  3d  of  August,  and  had  effectually  closed 
the  war.  No  cholera  had  occurred  among  the  troops  in  immediate  at- 
tendance upon  General  Scott  after  leaving  Chicago.  He,  joining  the  com- 
mand of  General  Atkinson,  descended  the  river  to  Rock  Island,  where  the 
regular  troops  were  encamped  at  or  near  Fort  Armstrong,  on  Rock- 
Island,  which  post  had  been  abandoned  for  some  time.  The  volunteer 
troops  were  already  on  the  homeward  march. 

It  was  a  matter  of  the  greatest  solicitude  to  General  Scott  to  prevent 
the  meeting  of  any  troops  who  might  be  on  the  march  from  Chicago  and 
the  returning  volunteers.  It  was  equally  a  matter  of  solicitude  on  his 
part  to  prevent  four  companies  of  Rangers,  then  being  raised  in  the 
counties  adjacent  to  the  Ohio,  from  contact  with  Chicago  or  the  troops 
who  had  suffered  so  severely  at  Fort  Dearborn.  The  report  of  General 
Scott  so  clearly  defines  the  impression  which  experience  had  graven  upon 
his  mind  of  the  necessity  of  isolating  those  Avho  were  infected  with  cholera 
from  those  who  had  not  been  exposed,  that  I  reproduce  extracts  from  his 
report  to  the  Honorable  the  Secretary  of  War. 

Headquarters  Northwestern  Army,  Rock  Island,  September  1,  1833. 
Sir: 

"  The  manner'  of  the  introduction  of  this  disease  among  the  troops 
which  had  been  serving  under  the  immediate  orders  of  Brigadier-General 
Atkinson  is  to  me  an  affecting  speculation. 

"  I  have  already  reported  many  of  the  measures  adopted  by  me  to  pre- 
vent the  spread  of  the  disease  from  that  place  [Fort  Dearborn,  Chicago] 
among  the  inhabitants  of  the  country,  volunteers,  and  United  States 
Rangers;  but  I  have  not  reported  half  of  my  care  and  solicitude  on  the 
subject,  nor  is  it  possible  for  me  to  do  much  more  on  the  present  occa- 
sion. I  left  Chicago  on  the  morning  of  the  29th  of  July.  The  disease 
among  the  troops  there,  as  we  all  thought,  had  nearly  exhausted  itself. 

"  I  hastily  addressed  a  letter  of  instructions  to  Colonel  Eustis,  second 
in  command,  of  which  the  following  are  extracts: 

"'  '  From  a  letter  just  received  from  the  Secretary  of  War,  I  find  it  is  his 
opinion,  on  account  of  cholera,  that  the  movements  of  detachments  in- 
fected with  that  disease  should  not  be  precipitated.  You  are  fully  aware 
of  my  own  policy  to  guard  against  the  spread  of  the  calamity.     I  shall 


74 


ASIATIC  CHOLERA. 


therefore  leave  you  tlie  same  discretion  (to  march  or  not  to  march)  which 
I  have  heretofore  exercised  myself  on  that  critical  snbject;  but  hope  by 
the  arrival  of  Lientenant-Colonel  Cummings'  small  detachment,  if  not 
before,  it  may  be  deemed  safe,  in  respect  to  humanity  and  the  good  of  the 
service,  for  you  to  take  up  the  line  of  march. 

"  '  You  will,  as  long  as  new  cases  of  cholera  shall  happen  to  occur  here 
or  on  the  march,  take  all  proper  measures  to  avoid  a  junction  with  Rangers 
or  volunteers,  but  long  before  you  reach  the  Mississippi  I  trust  your  bat- 
talion will  cease  to  be  suspected  of  cholera. 

"  '  1  have  kept  you  up  to  this  time  so  fully  acquainted  with  my  corre- 
spondence and  views,  with  all  authorities  and  on  all  subjects,  and  my  con- 
fidence in  your  intelligence,  zeal  and  abilities  is  so  great,  that  I  deem 
it  superfluous  to  say  more  to  you  at  present.  I  know  well  that  I  leave  the 
public  interests  in  safe  and  able  hands.' 

"  By  the  misconduct  of  two  express  riders  (one  of  whom  lost  his  dis- 
patches) I  did  not  hear  from  Colonel  Eustis,  after  he  left  Turtle  Eiver, 
till  the  night  of  the  21st  ultimo,  when  a  part  of  his  troops  in  boats  were 
actually  at  the  mouth  of  Rock  river,  three  miles  below.  His  letter  was 
dated  the  16th  of  that  month,  at  Dixon's  ferry.  He  arrived  himself  by 
land,  near  the  mouth  of  Rock  river,  the  same  night  (with  the  remainder 
of  his  troops)  that  I  received  his  letter.  On  the  morning  of  that  day  I 
stated  to  you  that  '  a  few  old  and  lingering  cases  of  cholera  Avere  on  the 
boats.' 

''  This  was  founded  on  rumor,  and  was  a  mistake.  On  visiting  his 
camp,  on  the  22d,  I  had  the  happiness  to  learn  that  there  had  not  been  a 
new  or  old  case  of  cholera  among  his  troops  after  his  passage  of  Turtle 
river  on  the  13th  ultimo,  one  hundred  and  thirty  or  one  hundred  and 
forty  miles  from  this.  I,  nevertheless,  by  order,  confined  his  troops  to  an 
island  in  Rock  river,  and  interdicted  all  communication,  except  by  my 
special  permission,  between  his  camp  and  the  other  troops,  or  inhabitants 
of  the  neighborhood;  that  is,  one  family,  a  mile  above  him,  on  another 
island,  and  one  family  on  this  side  of  Rock  river.  Neither  of  these  fami- 
lies, as  far  as  I  have  heard,  has  been  infected,  nor  was  there  a  single  case 
of  cholera  in  his  camp  down  to  last  evening.  Myself,  an  aide-de-camp 
and  one  other  officer  were  the  only  persons  who  had  visited  that  camp 
from  this  island,  and  neither  of  us  has  been  infected. 

"  On  the  12th  ultimo  I  caused  a  letter  to  be  addressed  to  Colonel 
Eustis  (which  he  acknoAvledged  at  Dixon's  Ferry  on  the  16th),  of  which 
the  following  is  an  extract: 

"  '  The  general  is  very  desirous  that  you  should  take  great  pains  to 
avoid  all  communication,  either  with  the  inhabitants  of  the  country  or 
with  other  troops,  should  any  new  case  of  cholera  have  occurred  on  the 
march.' 

"  This  was  written  when  I  knew  that  the  volunteer  militia  would  be 
returning  home  by  Dixon's  ferry,  and  that  certain  companies  of  the 
United  States  Rangers  might  be  expected  there  on  their  way  to  join  me. 
I  believe  the  volunteers  returning  home  had  all  passed  to  the  east  before 
Colonel  Eustis  arrived,  but  he  met  or  found  there  Captain  Ford's  company 
of  United  States  Rangers,  and  it  is  known  that  some  communication  per- 
sonally took  place  between  the  officers  of  the  two  bodies,  if  not  between 
their  men,  as  well  while  near  Dixon's  as  afterward,  on  their  march  hither, 
Captain  Ford  following  the  trail  of  Colonel  Eustis  at  a  distance  generally 
of  eight  or  ten  miles  till  the  latter  encamped  on  an  island  in  Rock  river. 


THE  EPIDEMIC  IN  THE  UNITED  STATES  AEMY  IN  1832.        75 

and  then  the  former  crossed  a  half-mile  above.  These  facts  are  by  others 
deemed  important  as  to  the  introduction  of  cholera  here,  but  not  by  me, 
though  they  certainly  show  a  neglect  of  my  reiieated  instructions.  Colonel 
Eustis,  ahvays  a  non-contagionist,  had,  on  reaching  the  ferry  (Dixon's), 
been  three  or  four  days  without  a  case  of  the  disease,  either  new  or  old, 
and,  therefore,  became  too  confident  that  his  oflBcers  and  men  could  not 
impart  it  to  others. 

"  But  Captain  Ford's  company,  which  has  clearly  infected  this  island, 
and  through  it  will,  I  fear,  infect  the  whole  valley  of  the  Mississippi,  in 
all  probability  imbibed  the  contagion  at  Chicago.  At  that  place,  and  on 
my  Avay  westward,  I  had  filled  the  whole  country  south  and  east,  through 
newspapers,  by  innumerable  letters  (four  of  Avhicli  Avere  to  the  four  cap- 
tains of  Eangers  on  this  side  of  the  Mississippi),  through  discharged  volun- 
teers on  the  Illinois  and  Eock  Island  rivers,  and  other  means,  with  ad- 
monitions to  Rangers  not  to  approach  Chicago.  I  had  sent  the  arms  of 
the  four  companies  to  Danville  and  Dixon's  ferry  in  the  same  view,  and 
informed  each  captain  where  to  find  his  own,  and  to  give  like  information, 
if  he  could,  to  the  three  others.  These  letters  Avere  all  left  iinsealed,  and 
indorsed  Avith  my  rank  and  name  to  excite  curiosity,  and  to  induce  post- 
masters and  others  to  read  them  and  give  publicity  to  my  admonitions. 
In  short,  I  had  erected  a  pajDer  barrier  around  Chicago  Avliich  no  company 
of  Eangers,  though  ordered  to  report  to  me  there,  could  ignorantly  pass. 
In  the  mean  time,  and  down  to  the  arrival  of  Captains  Boon  and  Ford 
here,  I  had  not  received  a  line  from  either  of  the  captains,  except  BroAvn, 
Avho  was  recruiting  at  Danville. 

"  Captain  Ford,  on  his  march  from  the  Ohio  river,  did  not  ignorantly 
pass  the  barrier  I  have  mentioned.  On  his  arrival  at  Captain  Orr's  camp 
on  Hickory  Creek,  thirty-five  miles  from  Chicago,  he  learned  from  the 
latter  (an  excellent  officer)  my  solicitude  on  the  subject  of  cholera.  He 
had  seen  one  of  my  published  letters  to  the  siime  effect.  Nevertheless, 
Avith  fourteen  of  his  men,  he  went  up  to  Chicago  for  provisions,  and  suf- 
fered himself,  Avith  some  of  his  men,  to  be  coaxed  into  Fort  Dearborn. 
This  was  about  the  lOtli  ultimo.  Twelve  days  afterAA^ard  Captain  Ford's 
company  arrived  here,  and  on  the  night  of  the  25  th  ultimo  sent  a  sick 
man  (Johnson)  across  into  Fort  Armstrong,  avIio  has  proved  to  be  a  case 
of  cholera,  and  is  the  first  on  this  island.  This  man  was  one  of  those  Avho 
went  up  to  Chicago,  and,  if  not  into  Fort  Dearborn,  was  certainly  at  the 
entrance  of  the  cholera  hospital,  then  reeking  Avith  recent  disease. 

"  The  second  case  and  first  death  Avas  another  man  (Hall)  of  the  same 
company.     He  Avas  brought  into  the  hospital  here  and  died  on  the  26th. 

"  Here  again  I  have  had  all  my  care  and  sagacity  singularly  defeated 
by  accident  or  ignorance.  I  had  visited  Captain  Ford's  company  camp, 
and,  on  seeing  tAvo  of  his  men  sick  of  fever,  directed  that  cases  requiring 
care  in  the  treatment  should  be  sent  to  the  hospital  in  Fort  Armstrong. 
I  was  then  ignorant  that  any  part  of  the  company  had  been  near  Chicago 
or  had  any  intercourse  with  Colonel  Eustis's  command  at  Dixon's  Ferry. 
The  day  that  Johnson  was  sent  over  to  this  island,  Captain  Ford  told  me 
that  he  had  a  third  man  sick  of  common  cholera,  Avhom  he  wished  to  send 
to  the  hospital.  Being  about  to  leave  the  fort  for  Colonel  Eustis's  camp, 
I  directed  one  of  the  surgeons  here  to  keep  Avatch  for  that  man  at  the 
Avater's  edge,  in  order  to  see  if  the  case  Avere  not  one  of  spasmodic  cholera, 
and  if  so,  not  to  permit  him  to  be  landed.  Dr.  Coleman  had  never  before 
seen  a  case  of  that  sort,  and  receiA'ed  Johnson  through  a  very  natural 


76 


ASIATIC  CHOLERA. 


ignorance.  The  disease  not  being  early  developed,  I  myself,  on  repeated 
inspections  doubted  its  character  until  after  I  had  the  honor  of  addressing 
you  on  the  morning  of  the  2Gth,  and  therefore  did  not  mention  it.  80 
afterward,  on  the  26th,  another  ranger  (Hall)  was  introduced.  He  was 
received  by  the  other  surgeon,  Dr.  Smith,  after  a  similar  caution  from 
me,  and  died  in  a  few  hours  of  cholera.  We  had  but  one  case,  a  man 
of  the  Fourth  Infantry,  on  the  27th,  wdio  lay  in  the  hospital  (a  case  of 
debility)  with  Johnson  on  the  night  of  the  25th.  On  the  30th  the  disease 
began  to  rage  among  all  the  troops  on  this  island.  Strange  to  say,  that 
not  another  case  occurred  in  the  camp  of  rangers  (on  the  west  side  of  the 
Mississippi)  from  the  26tli  down  to  this  morning.  Two  more  are  now 
reported,  and  I  fear  that  the  usual  havoc  will  follow  among  the  drunken 
and  feeble.  *        *        * 

"  September  2. 

"  During  the  panic  on  the  night  of  the  30th,  seventeen  men  of  the 
Sixth  Infantry,  who  mostly  have  families  at  Jefferson  Barracks,  stole  a 
boat  and  deserted.  It  is  supposed  they  have  gone  thither.  Many  of  them 
will  probably  perish  by  the  way  and  the  remainder  infect  the  barracks  and 
St.  Lou- is.  On  the  morning  of  the  29th  at  daylight,  I  sent  off  by  water, 
under  guard,  seven  prisoners,  five  of  whom  were  principal  chiefs  or  war- 
riors of  Black  Hawk's  band,  to  be  confined  as  hostages  at  Jefferson  Barracks 
during  the  pleasure  of  the  President  of  the  United  States.  This  measure 
was  taken  on  the  night  of  the  28th,  after  consulting  G-overnor  Eeynolds 
who  Avas  present),  and  with  his  concurrence.  I  at  the  same  time  de- 
livered up  to  Ke-o-kuck  and  other  friendly  chiefs  then  here  all  the  old 
men,  the  women  and  children  who  were  under  guard  as  prisoners  of  war, 
and  sent  the  whole  away. 

"  These  precautions  were  taken  in  haste,  before  the  cholera  had  spread 
beyond  the  third  case,  Avhich  happened  on  the  27th,  and  when  we  hoped 
that  neither  the  guard  of  the  hostages  nor  any  Indian  sent  away  had  im- 
bibed the  disease.  The  rapid  spread  which  commenced  on  the  night  of 
the  29th  has  given  us  great  uneasiness  on  this  point.  AVe  had  remaining 
the  three  murderers  of  the  Menomonees,  the  murderer  of  one  of  our  citi- 
zens near  the  Yellow  Banks,  and  some  young  men  Avhose  quality  we  had 
not  ascertained.  Two  other  warriors  were  brought  up  from  the  friendly 
villages  below,  on  the  29th,  after  the  hostages  were  gone.  Of  these 
Indians  four  were  already  reported  as  dead  of  the  epidemic  and  several 
others  were  sick. 

"  I  have  the  honor  to  be,  sir,  with  great  respect, 

"  Your  most  obedient  servant, 

"  Hon.  Lewis  Cass,  "  AYinfield  Scott. 

"Secretary  of  War." 

On  the  16th  of  September,  it  was  officially  reported  that  cholera  had 
entirely  disappeared  from  among  the  troops  on  Rock  Island,  and  that  it 
was  fast  subsiding  in  the  camp  of  the  Rangers  on  the  west  side  of  the 
river. 

On  the  lOtli  of  September,  it  was  reported  that  at  Jefferson  Barracks, 
Missouri,  the  cholera  was  epidemic.  At  this  post  on  September  4th  a 
party  of  deserters,  fifteen  (15)  in  number,  from  Rock  Island,  arrived  and 
surrendered  themselves,  stating  that  they  had  deserted  from  the  cholera 
alone;  and  they  were  followed  by  other  deserters  who  had  descended  the 
river  in  canoes.     Of  such  a  party  Surgeon  McMahon  reported  that  on 


THE  EPIDEMIC  IN  THE  UNITED  STATES  ARIMY  IN  1832.        77 

the  9tli  of  the  month  one  man  had  been  brought  ashore  "  in  the  last  stage 
of  collapse/^ 

From  Jefferson  Barracks  the  disease  was  carried  into  the  city  of  St. 
Lonis;  and  at  a  later  date  by  two  companies  of  Rangers  (Boone's  and  Ford's) 
to  Forts  Gibson  and  Smith  in  Arkansas.  From  St.  Louis  cholera  was 
carried  on  steamboats  down  the  jMississippi  river,  and  up  the  Ohio  river, 
where  at  Cincinnati  it  met  lines  of  infection  which  had  crossed  from  Erie 
to  Pittsburgh,  Penn.,  and  from  Cleveland  to  Cincinnati,  Ohio.  From 
Cincinnati  a  broad  trail  of  infection  crossed  into  and  through  the  State 
of  Kentucky,  thence  through  the  State  of  Tennessee  to  the  city  of  Mem- 
phis, where  it  joined  the  course  of  river  infection  and  descended  upon  the 
city  of  New  Orleans,  in  which  city  six  thousand  (6,000)  deaths  are  said  to 
have  occurred. 

On  the  8th  of  November,  Lieutenant-Colonel  Foster  reports  from  Baton 
Rouge,  Louisiana,  that  '^cholera  is  upon  every  boat  which  passes  u]d  and 
down  the  river." 

It  does  not  seem  possible  that  a  clearer  demonstration  of  the  agency  of 
individuals  in  the  diffusion  of  epidemic  cholera  could  be  made.  It  does 
not  seem  possible  that  a  clearer  demonstration  of  the  cholera  truths  which 
have  been  formulated  at  the  opening  of  this  chapter  could  be  made. 

Official  records  show  that  the  body  of  troops  which  embarked  on  the 
Henry  Clay  at  the  city  of  Buffalo,  N.  Y.,  on  the  1st  day  of  July,  1832, 
Avere  in  good  physical  condition.  By  Colonel  Twiggs,  under  whose  com- 
mand they  embarked,  they  were  spoken  of  as  the  finest  body  of  recruits 
he  had  ever  seen.  •  The  Henry  Clay  had  been  employed  in  the  transporta- 
tion of  cholera-infected  emigrants  from  the  St.  Lawrence  river.  On 
the  fourth  day  after  embarkation,  cholera  broke  out  among  these  troops, 
and  when  the  Henry  Clay  reached  the  Detroit  river  they  were  suffering 
frightfully  from  epidemic  cholera.  At  Detroit  they  were  joined  by  two 
other  commands,  one  consisting  of  eight  companies  who  had  not  been  ex- 
posed to  the  infection,  and  an  isolated  company  in  Detroit  that  had  been 
brought  to  that  city  on  a  steamboat  Avhich  had  been  exposed  to  cholera 
in  the  persons  of  emigrants,  as  was  the  Henry  Clay.  The  virulence  of 
the  epidemic  on  the  Henry  Clay  started  the  epidemic  flame  in  the  other 
commands,  and  in  but  a  day  or  two  the  numerical  strength  of  the  com- 
mands had  gone.  One  steamboat  with  six  companies  on  board  passed 
through  the  Saint  Clair  and  ascended.  Lake  Huron,  but  at  Mackinaw  she 
landed  four  fatal  cases  of  cholera,  and  passing  on  in  descending  Lake 
Michigan  the  disease  on  her  decks  raged  so  violently  that  she  arrived  a  pest- 
ship  at  Chicago — an  absolutely  healthy  point  prior  to  her  arrival.  At  Chi- 
cago the  disease  raged  until  all  material  was  well-nigh  exhausted.  So  far 
as  it  was  able,  it  spread  in  the  then  sparsely  settled  country,  but  presently 
the  embers  alone  were  left.  By  a  gross  disobedience  of  orders  fresh  victims 
were  infected.  By  them  the  disease  Avas  carried  over  one  hundred  and 
fifty  miles  of  almost  wilderness  to  the  Mississippi  river,  when  the  troops 
under  General  Atkinson,  returning  from  a  victorious  campaign,  were  in- 
fected and  an  epidemic  started  which  cost  thousands  of  lives. 

Cholera  visited  the  United  States  in  the  years  1833,  1834  and  1835,  but 
no  evidence  can  be  found  that  the  troops  had  any  agency  in  its  spread  during 
either  of  those  years.  It  is  a  notorious  fact  that  steamboats  on  the  Missis- 
sippi, Ohio  and  Missouri  rivers  were  cholera-infected,  and  that  their  agency 
in  the  diffusion  of  cholera  in  those  years  was  as  great  as  it  has  been  in 
succeeding  epidemics. 


78  ASIATIC  CHOLERA. 

I  find  from  the  reports  of  Surgeon  R.  C.  Wood,  U.  S.  Army,  that  at 
Fort  Crawford,  on  Prairie  du  Chien,  cholera  occurred  in  August,  1833; 
that  there  were  twenty-three  (23)  decided  cases  with  six  (6)  deaths,  while 
very  few  escaped  the  choleraic  diarrhoea,  and  that  at  the  same  time  in  the 
town  of  Prairie  du  Chien  twelve  or  fifteen  deaths  occurred. 

The  garrison  of  Fort  Leavenworth,  Kan.,  Jefferson  Barracks,  Mo.,  and 
Jackson  Barracks,  La.,  were  infected  in  1833;  and  the  disease  appeared 
at  Fortress  Monroe,  Va.,  and  Jefferson  Barracks  in  1834,  while  in  that 
year  the  timely  removal  of  the  garrison  of  Jackson  Barracks  "  saved  them 
from  total  destruction.^' 

The  epidemic  of  1832  was  not  confined  to  troops  and  citizens;  the  In- 
dians, who  were  released  by  General  Scott  after  cholera  attacked  the 
troops  at  Rock  Island,  were  attacked  with  the  disease  before  and  after 
they  reached  their  homes,  and  that  it  continued  epidemic  among  them  is 
evident  from  the  fact  that  the  bodies  of  troops  who  Avere  employed  on 
summer  scouts  in  the  Indian  country  along  and  between  the  Mississippi 
and  Missouri  rivers,  almost  invariably  suffered  from  the  disease  during 
the  years  of  1833  and  1834. 


THE  EPIDEMICS  OF   1848   TO   1857.  79 


CHAPTEK  XIII. 

THE  EPIDEMICS  OF  1848,  1849,  1850  TO  1857. 

The  arrival  of  the  ship  Swanton  with  a  cholera  cargo,  at  New  Orleans 
on  the  11th  day  of  December,  1848  was  followed  by  an  epidemic  outbreak 
which  was  soon  carried  to  the  U.  S.  troops  serving  in  Texas.  Late  in 
December  a  schooner  arrived  at  Fort  Polk,  at  the  mouth  of  the  Eio  Grande, 
from  New  Orleans,  having  on  board  forty  (40)  Mexican  soldiers  and  their 
families.  These  men  had  served  as  allies  to  the  U.  S.  troops  between 
A'era  Cruz  and  the  city  of  Mexico  in  the  then  late  war.  The  vessel  hav- 
ing arrived  during  a  "  norther  "was  detained  off  the  Brazos  bar,  and  while 
at  anchor  a  number  of  cases  of  cholera  occurred  on  board,  one  of  which 
died.  After  crossing  the  bar  tliree  cases  were  admitted  to  the  post 
hospital,  one  being  fatal.  After  some  delay  the  remainder  of  this  com- 
pany proceeded  to  Brownsville,  Texas,  January  24,  1849,  where  their 
baggage  was  opened  preparatory  to  their  dispersing  to  their  homes.  On 
the  20tli  of  February  a  malignant  epidemic  of  cholera  broke  out  in  the 
town  of  Brownsville,  Texas,  and  in  Matamoros,  Mexico,  on  the  opposite 
bank  of  the   Rio  Grande. 

The  disease  appeared  almost  simultaneously  in  the  garrison  of  Fort 
Brown. 

In  Brownsville  the  epidemic  influence  extended  over  a  period  of 
thirty  days,  and  in  that  time  one  hundred  and  twenty  (120)  deaths 
occurred,  one  sixth  of  the  inhabitants.  At  Fort  Brown  twenty- 
one  (21)  cases,  with  twelve  (12)  deaths  occurred  and  at  Matamoros 
out  of  a  population  of  five  thousand  (5,000)  one  thousand  (1,000) 
died.  February  10th  one  fatal  case  occurred  at  Fort  Polk.  Feb- 
ruary 27th  the  epidemic  Avas  malignant  on  Brazos  Island,  off  the  mouth 
of  the  Rio  Grande.  March  5th,  the  disease  again  developed  at  Fort  Polk 
and  of  eleven  (11)  cases  six  (6)  were  fatal. 

From  Brownsville  and  Matamoros  the  disease  spread  through  the  Rio 
Grande  valley,  and  Camargo  lost  one-third  of  its  inhabitants,  the  town  of 
Roma  and  many  villages  were  depopulated.  Doctor  Jarvis  notes  that  the 
cholera  transmission  along  that  river  may  be  easily  accounted  for  by  the 
number  of  emigrants  passing  up  on  their  way  to  California,  and  who  suf- 
fered severely  at  different  points  from  the  same  pestilence. 

At  Ringgold  Barracks  on  the  Rio  Grande  above  Brownsville,  the  dis- 
ease appeared  March  2d  in  the  person  of  a  soldier,  and  during  the  month 
twenty-three  (23)  cases  with  fourteen  (14)  deaths  occurred.  The  impor- 
tation of  cholera  to  this  post,  is  very  clearly  shown  in  the  report  of  Assist- 
ant Surgeon  N.  S.  Campbell.  "  On  the  2Tth  of  February,  1849,  the  U.  S. 
steamer  Corvette  arrived  at  the  post  from  Brownsville,  at  which  latter  place 


gQ  ASIATIC   CHOLERA. 

the  cliolera  was  raging.  On  her  passage  up  the  river,  one  passenger  a  Cali- 
fornian  emigrant,  died  of  cholera;  another  passenger  was  attacked  but  re- 
covered ;  and  the  mate  of  the  boat  was  attacked  by  the  same  disease,  and  died 
soon  after  his  arrivaL  Des2:)ite  all  remonstrances,  the  boat  was  permitted  to 
come  to  the  usual  landing  place  for  U.  S.  boats,  near  the  center  of  the 
garrison;  and  on  the  28th,  immediately  after  muster,  the  whole  command 
was  ordered  to  unload  the  boat.  They  did  so,  and  the  steamer  left  on 
the  morning  of  March  2d.  At  10  o'clock,  a.m.,  on  that  day  the  first  ease 
occurred,  and  in  one  of  the  men  employed  in  unloading  the  Corvette." 

On  March  11th  18-49,  a  squadron  of  the  second  U.  S.  dragoons  left 
Ringgold  Barracks,  and  after  a  march  of  five  (5)  days  arrived  at  Laredo, 
Texas,  a  distance  of  125  miles.  After  leaving  Einggold  Barracks  cholera 
broke  out  in  the  command,  fourteen  (14)  cases  with  ten  (10)  deaths  oc- 
curred, with  thirty  (30)  cases  of  acute  diarrhoea.'  Laredo  was  at  this 
time  occupied  by  a  command  of  the  1st  U.  S.  Infantry,  who  were  en- 
camped on  the  military  plaza  in  the  center  of  the  town.  On  reaching 
Laredo,  the  dragoons  were  encamped  on  the  river  bank  outside  the  town, 
and  after  making  this  camp  but  one  case  of  the  disease  occurred  among 
them.  The  camp  of  the  1st  Infantry  in  the  town,  however,  became  in- 
fected. "  The  old  military  plaza  that  was  surrounded  with  the  refuse  of 
a  hundred  years  became  a  perfect  hot-bed  for  propagating  the  cholera 
germ,  and  for  several  days  in  succession  the  new  guard  buried  the  old 
guard  in  the  clothes  they  had  on.  Many  died  in  less  than  an  hour  after 
they  were  attacked. "  " 

A  second  importation  of  cholera  into  the  State  of  Texas  is  to  be  found 
in  the  movements  of  the  Stli  U.  S.  Infantry.  This  regiment  had  served 
in  Mexico  during  the  war,  and  in  October,  1848,  had  reached  the  city  of 
St.  Louis,  Mo.,  en  route  for  New  Mexico;  when  from  orders  there  received 
they  again  descended  the  Mississij)pi  river  and  arrived  in  New  Orleans  on 
the  1st  of  December,  1848.  At  New  Orleans  the  regiment  was  quartered  at 
Jackson  Barracks,  where  it  remained  until  December  12th,  when  it  em- 
barked upon  the  steamers  Telegraph  and  New  Orleans  en  route  for  Texas. 
December  15th,  they  arrived  at  Port  Lavacca,  Texas,  but  they  were  not 
landed  until  the  19th,  when  a  camp  was  established  about  two  miles 
from  the  town.  On  the  21st,  one  battalion  was  marched  twelve  miles  into 
the  country.  The  same  night  cholera  had  attacked  both  camps,  and  by 
the  morning  of  the  22d  more  than  one-eighth  of  l^otli  commands  had  the 
disease.'  The  disease  continued  with  great  violence  until  the  30th. 
In  one  hundred  and  ninety-six  (19G)  cases  there  were  one  hundred  and 
thirty-three  (133)  deaths,  and  many  women  and  children  belonging  to  the 
regiment  died  of  the  disease.  This  command  did  not  reach  San  Antonio, 
Texas,  until  some  time  in  the  month  of  February,  1849,  and  no  record  of 

'  Report  of  Asst.  Surgeon  Glover  Perin,  U.  S.  A. 

-  Statement  of  Gen.  E.  L.  Viele.     Journal  Mil.  Ser.  Inst.,  March,  1885. 

^In  a  recent  paper  on  "Camp  and  Garrison  Sanitation,"  published  in  the  Journal 
of  the  Militaiy  Service  Institution,  March,  1885,  Gen.  E.  L.  Viele  has  followed  an 
error  which  occurred  in  my  History  of  Cholera  in  America,  namel3\  tliat  the 
8th  U.  S.  Infanty  carried  cholera  into. the  State  of  Texas  in  1848,  and  were  re- 
sponsible for  its  epidemic  diffusion.  I  cannot  find  that  the  cholera  infection 
of  this  regiment  spread  to  other  troops.  When  that  command  reached  San  An- 
tonio it  was,  according  to  reports,  free  from  the  disease.  It  is  more  probable  that 
General  Worth  became  infected  with  cholera  on  liis  journey  from  New  Oi'leans  to 
San  Antonio.     Report  of  Sui-geon  Madison  Mills,  U.  S.  A. 


THE  EPIDEMICS  OF   1848   TO  1857.  gj 

any  cases  of  cholera  having  occurred  among  it  can  be  found  for  some  time 
before  and  after  they  reached  the  city. 

The  movements  of  emigrants,  large  numbers  of  Avhom  arrived 
at  Xew  Orleans  in  December,  1848,  and  the  early  months  of  1849, 
had  undoubtedly  been  the  most  active  cause  of  the  diffusion  of 
cholera.  During  those  months  every  steamboat  upon  the  Gulf  coast 
^v^as  a  floating  pest-house.  Emigrants  flocked  unchecked  over  every 
line  of  travel,  and  it  is  most  probable  that  cholera  was  epidemic  in 
the  city  of  San  Antonio  early  in  the  month  of  April,  although  the  troops 
were  not  affected  until  May  1st,  when  cholera  broke  out  in  the  camji  of 
six  companies  of  the  3d  U.  S.  Infantry  at  Saledo  near  San  Antonio,  The 
third  day  after  the  first  case  occurred,  and  when  it  was  convalescent,  the 
stream  on  which  the  camp  was  situated  suddenly  rose  about  twenty  feet 
and  flooded  the  camp.  Most  of  the  command  were  obliged  to  swim  in 
escaping  from  camp  to  a  higher  ground  of  the  prairie.  All  were  wet  and 
lay  all  night  on  the  prairie,  without  tents  or  other  covering,  during  the 
heavy  rain.  The  next  day  was  one  of  great  fatigue  for  the  men.  On  the 
second  day  three  cases  of  cholera  occurred."'  Seventy-five  (75)  cases 
occurred,  of  which  twenty-eight  (28)  died.  The  last  case  occurred  May 
15.  On  the  7th  of  May,  Major-General  Worth  died  of  cholera  at  San 
Antonio;  he  had  but  recently  returned  from  Xew  Orleans.^  Xo  other 
record  of  cholera  having  affected  other  bodies  of  troops  in  Texas  can  be 
found,  but  in  Fenner's  Medical  Keport  for  1849,  Surgeon  Jarvis,  U.S.A., 
shows  how  cholera  was  diffused  through  Texas  by  emigrants  and  into 
^Mexico  by  refugees  from  Texas. 

The  epidemic  of  1848  was  continued  into  the  following  year  in  other 
localities.  In  the  months  of  July  and  August,  1849,  nineteen  (19)  cases 
Avith  fifteen  (15)  deaths  occurred  on  Governor's  Island,  Xew  York  harbor. 
At  Carlisle  Barracks,  Penn,,  a  recruit  received  from  Governor's  Island 
died  of  cholera  in  July,  and  eleven  (11)  cases  with  three  (3)  deaths  occurred 
in  quick  succession.  At  the  Military  Academy  at  West  Point,  X.  Y. ,  on 
July  17th,  "a  fatal  case  of  dysentery,"  showing  in  a  very  marked  degree 
toward  its  close  some  of  the  symptoms  of  cholera,  had  occurred,  and  on 
August  11th  an  unmistakable  cholera  death  occurred.  In  all  there  were 
five  (5)  cases  and  three  (3)  deaths.  At  this  time  cholera  was  common 
along  the  line  of  the  Hudson  Eiver  Railroad,  and  at  the  smaU  town  of  Can- 
terbury (12  miles  distant)  twenty  deaths  had  occurred." 

At  NeAvport  Barracks,  Ky.,  eighty-five  (85)  cases  with  five  (5)  deaths 
were  reported.  On  July  1st  cholera  was  reported  at  the  Detroit  Barracks; 
it  is  reported  that  but  one  soldier  died  of  the  disease  and  only  about  one 
hundred  in  the  city  of  Detroit  ''including  those  landed  from  the  steam- 
boats." ' 

It  cannot  be  shown  that  either  of  the  posts  named  Avere  centers  of  in- 
fection and  of  diffusion,  save  in  the  instance  alone  of  Governor's  Island; 
but  from  the  Mississippi  river  westward,  the  trail  of  epidemic  diffusion  is 
very  plain.  The  years  of  1848  and  1849  and  those  immediately  succeed- 
ing were  the  years  of  ''rush"  for  California.  Many  Avere  emigrants,  but 
the  majority  Avere  of  the  restless  population  of  the  United  States.     Num- 

'  Report  of  Asst.  Surgeon  L.  H.  Stone,  U.  S.  A. 

-  Report  of  Surgeon  J.  J.  B.  Wright,  U.  S.  A.  / 

^  Report  of  Surgeon  J.  M.  Cuyler,  U.  S.  A, 

^  Report  of  Surgeon  Chas.  S.  "Tripler,  U.  S.  A.  j 

6 


32  ASIATIC  CHOLERA. 

bers  of  these  California  emigrants  were  carried  by  Atlantic  steamers  to 
the  Isthmus  and  by  Pacific  steamers  to  San  Francisco — but  thousands 
traveled  overland,  many  by  the  southern  routes  through  Texas — and  thou- 
sands from  the  Missouri  river.  The  starting  points  of  this  latter  class 
were  Independence  and  St.  Joseph,  Mo. ;  Leavenworth,  Kansas,  Omaha, 
Nebraska,  and  other  Missouri  river  towns. 

In  the  early  months  of  1849  cholera  was  almost  universally  diffused 
over  the  Mississippi  valley,  and  almost  all  the  river  steamboats  were  in- 
fected. Early  in  April  the  disease  was  epidemic  in  St.  Louis  and  in  the 
preceding  month  the  steamboats  on  the  Missouri  river  were  reinfected. 
April  21,  the  steamboat  Sacramento  landed  a  large  number  of  cholera-in- 
fected emigrants  at  St.  Joseph,  Mo.  She  was  ra]3idly  followed  by  other 
boats,  also  infected.  On  the  steamboat  Mary  over  fifty  (50)  cholera 
deaths  had  occurred  after  she  left  St.  Louis.  What  is  stated  of  cholera 
arrivals  at  St.  Joseph  is  also  true  as  to  Independence,  Leavenworth,  Omaha, 
and  other  river  towns.  At  these  points  outfits  were  obtained,  messes  were 
formed,  and  for  mutual  protection  large  companies  marched  from  these 
rendezvous,  carrying  the  cholera  poison  with  them.  As  the  years  from 
1848  to  1855  were  years  of  gold  excitement  and  the  flood  of  California 
travel,  so  were  they  years  of  almost  uninterrupted  cholera  diffusion  over 
that  vast  territory  which  lies  west  of  the  Mississippi  river.  One  broad 
trail  of  emigrant  travel  extended  westward  through  Kansas  along  the  line 
of  the  Smoky  Hill  fork  of  the  Kansas  river.  Another  was  through  Ne- 
braska along  the  line  of  the  Platte  river.  From  Independence,  Mo. ,  Leav- 
enworth, Kan.,  St.  Joseph  Mo.,  and  Omaha,  Neb.,  these  lines  of  travel 
converged  and  crossed  each  other  at  various  points  before  the  broad  trail 
was  taken  up  on  the  Kansas  or  Nebraska  routes,  and  for  many  miles  west 
of  these  principal  rendezvous  the  country  was  marked  with  old  and  new 
camps.  The  favorite  camping-grounds  were  always  in  the  vicinity  of 
small  towns  and  villages;  for  even  in  the  excitement  for  the  El  Dorado, 
emigrants  were  loath  to  turn  their  backs  upon  the  abodes  of  man  so  long 
as  they  could  be  reached  without  deviation  from  their  line  of  march.  Dur- 
ing these  years  a  large  emigration  of  Mormons  was  taking  place,  and  thou- 
sands were  upon  the  march  for  Utah.  The  "  outfit"  of  a  party  of  emi- 
grants consisted  of  a  light  wagon,  in  which  women  and  children,  clothing, 
bedding,  food  and  such  articles  of  camp  furniture  as  they  possessed  were 
carried,  while  the  men  marched.  Many,  however,  did  not  possess  the 
means  to  obtain  this  luxury  and  all  contrivances  were  made  use  of — pack 
animals,  push  carts,  wheelbarrows — while  the  most  unfortunate  trusted 
to  their  own  broad  shoulders  to  bear  the  burden. 

In  June,  1849,  a  recruit  from  St.  Louis  died  of  cholera  at  Jefferson 
Barracks;  this  was  followed  by  eighty-one  (81)  cases  of  the  disease  with 
eleven  (11)  deaths.  The  epidemic  lasted  until  March  27th.  In  the  fol- 
lowing May  a  few  cases  occurred.  In  the  same  month  and  about  the 
same  date,  cholera  became  epidemic  at  Fort  Leavenworth,  and  lasted  until 
the  close  of  the  following  August.  At  this  post  the  medical  officer  reported 
that  the  epidemic  was  preceded  by  a  diarrlicea  which  seemed  to  affect  the 
entire  command,  as  it  did  the  inhabitants  of  the  surrounding  country. ' 
At  Fort  Kearny,  Nebraska,  one  case  of  cholera  occurred  in  the  person  of 
a  soldier  from  Fort  Leavenworth.  No  case  occurred  in  the  command  or 
at  the  post,  although  emigrants  passing  Avere  suffering  from  the  disease.  '^ 

'  Eeport  of  Surgeon  Chas.  McDoug-all,  U.  S.  A. 

-  Report  of  Asst.  Surgeon  Wm.  Hammond,  U.  S.  A. 


THE  EPIDEMICS  OF   1848  TO   1857.  33 

At  Fort  Laramie,  Wyoming,  the  only  instances  of  the  disease  were  in  three 
(3)  soldiers  who  had  formed  an  escort  party  from  Fort  Kearny,  one  of 
whom  had  cholera  late  in  July,  another  on  August  1st,  immediately  on 
their  arrival.  They  were  the  only  cases  at  the  post,  although  cholera  con- 
tinued epidemic  among  emigrants  to  a  point  fifty  (50)  miles  east  of  the 

230St. 

The  only  other  military  posts  from  which  reports  of  cholera  in  1849  can 
be  found  are  at  Fort  Smith,  Arkansas,  where  in  June,  Asst.  Surgeon  J,  H. 
Baily  reports  the  prevalence  of  cholera  on  Arkansas  river  boats  arriving  at 
the  post,  and  adds  that  there  has  been  but  "  little  proclivity  to  the  disease, 
either  among  the  troops  or  the  inhabitants  of  the  place. "  At  Fort  Gib- 
son, one  hundred  and  twenty  (12U)  miles  further  up  the  Arkansas  river. 
Surgeon  J.  B.  Wells  reports  cholera  upon  the  river  boats,  and  that  on  the 
15tli  of  July  the  disease  developed  in  the  5th  U.  S.  Infantry,  with  a  large 
number  of  cases  and  many  deaths. 

In  1850  cholera  was  still  epidemic  along  the  Mississippi  and  its  tribu- 
taries, and  river  steamers  were  again  the  porters  of  the  infection.  At 
Jefferson  Barracks  the  epidemic  opened  in  June  and  continued  to  August. 

In  June  a  non-fatal  case  occurred  among  the  garrison  of  the  St. 
Louis  Arsenal,  and  the  Medical  Officer"  reported  that  "  since  the  com- 
mencement of  May  very  unmanageable  cases  of  cholera  have  been  observed 
in  St.  Louis,  and  at  the  Arsenal  a  good  deal  of  diarrhoea  prevailed  among 
the  men." 

At  Fort  Kearny,  although  on  the  line  of  emigrant  travel  (among  the 
emigrants  the  disease  raged)  no  cases  are  reported.  In  the  spring  of  1850, 
a  large  detachment  of  recruits  left  Fort  Leavenworth  for  Fort  Laramie. 
This  command  was  perfectly  healthy  when  the  march  began  and  continued 
in  good  condition  until  the  line  of  march  met  the  emigrant  road  for  In- 
dependence on  one  side,  and  St.  Joseph  on  the  other;  then  they  were 
on  the  line  of  emigration,  and  when  they  arrived  at  the  Big  Blue  fork, 
cholera  broke  out  among  the  men.'  I  am  unable  to  find  any  record  of 
this  long  march  from  the  crossing  of  the  Big  Blue  to  Fort  Laramie,  where 
the  garrison  remained  healthy  until  after  the  arrival  of  this  body  of  re- 
cruits, although  in  this  year  the  emigrant  cholera  trail  extended  to  the 
upper  crossing  of  the  Platte  river,  a  distance  of  470  miles  from  the  cross- 
ing of  the  Big  Blue.  On  June  21st,  cholera  was  epidemic,  and  lasted 
until  July  20th.  Thirty  (30)  cases  in  all  occurred,  but  nine  (9)  of  whom 
were  old  soldiers.  Doctor  Moore  remarks  that  in  this  year  cholera  was 
confined  to  the  road  and  among  emigrants — but  many  Indians  remained  on 
the  road  from  curiosity  and  for  the  purpose  of  begging;  they  paid  a  ter- 
rible penalty.  Other  bodies  of  Indians,  wiser  than  these,  left  the  road  so 
soon  as  they  learned  there  Avas  disease  among  the  whites  and  escaped. 
During  this  year  many  sick  emigrants  were  left  at  this  post,  yet  the  disease 
did  not  spread. 

In  1851  cholera  was  still  epidemic  on  the  Mississippi  river,  and  the 
record  shows  that  Jefferson  Barracks,  in  June  of  that  year,  again  became 
a  center  of  infection.  It  is  not  improbable  that  the  epidemic  of  this  year 
Avas  caused  by  the  arrival  early  in  June  of  a  detachment  of  ninety  (90) 
recruits  for  the  regiment  of  mounted  rifles,  Avho  had  been  transported 

•  Report  of  Surgeon  S.  P.  Moore,  U.  S.  A. 

-  Asst.  Surgeon  Aberdie,  U.  S.  A. 

^  Report  of  Surgeon  S.  P.  Moore,  U.  S.  A. 


34  ASIATIC  CHOLERA. 

from  Carlisle  Barracks  on  a  canal-boat  to  Pittsburgh.  Penn.,  and  thence 
by  Ohio  River  steamboat  to  Jefferson  Barracks.  Cholera  broke  out  while 
on  the  Mississippi  river;  none  had  died  before  they  arrived  at  Jefferson 
Barracks,  but  C[uite  a  number  were  so  ill  on  arrival  that  they  were  carried 
to  hospital.     In  the  first  six  days  after  arrival  fifteen  (15)  had  died.' 

At  Fort  Leavenworth  cholera  was  epidemic  in  the  months  of  May,  June 
and  July.  The  reports  show  that  the  cholera  was  brought  from  St.  Louis 
with  troops.  At  Fort  Kearny  on  the  28th  of  June  a  case  of  cholera  oc- 
curred in  a  recruit  who  had  just  arrived  from  Fort  Leavenworth.  Xo 
other  cases  are  reported. 

At  Fort  Smith,  Arkansas,  on  the  31st  of  May,  two  companies  of  the 
5th  U.  S.  Infantry  arrived  from  Corpus  Christi,  Texas,  Avith  cholera  which 
had  broken  out  two  days  before  their  arrival.  The  companies  had  been 
transported  on  a  Mississippi  river  boat.  The  disease  infected  the  garrison 
and  an  aggravated  epidemic  occurred,  which  spread  to  the  town  and  lasted 
until  the  following  July.  Of  fifteen  hospital  attendants,  seven  (T)  had 
cholera,  two  (2)  died  and  four  barely  escaped  with  their  lives. '^ 

In  September  an  epidemic  outbreak  occurred  at  Newport  Barracks, 
Ky.  The  disease  had  previously  appeared  in  the  city  of  Newport,  and 
the  epidemic  was  remarkable  from  the  fact  that  but  nine  (9)  deaths  were 
reported  in  eighty-five  (85)  cases. 

In  1852,  a  few  cases  of  cholera  occurred  on  Governor's  Island,  in  Au- 
gust, and  at  Jefferson  Barracks  in  April,  May,  and  at  Fort  Leavenworth 
in  the  month  of  May.  A  few  cases  occurred  also  at  Newport  Barracks 
among  recruits  who  had  been  brought  by  steamboat  from  St.  Louis,  Mo. 

In  June  two  (2)  cases  occurred  at  Fort  Kearny.  The  men  had  both 
been  on  detached  service  at  the  village  of  Pawnee  Indians  on  the  Platte 
river,  about  thirty  miles  from  the  State  line.  No  other  cases  are  reported 
at  post — cholera  still  reported  as  being  among  California  emigrants.  In 
this  year  the  medical  officer  at  Fort  Laramie  reports  that  cholera  is  very 
virulent  among  emigrants,  over  one  thousand  of  whom  have  died  along 
the  Platte  route;  that  the  disease  has  affected  all  classes  of  emigrants, 
but  that  although  the  post  is  surrounded  by  them,  the  hospital  crowded 
Avith  their  sick,  and  that  almost  all  who  were  taken  sick  died,  yet  no  case 
occurred  among  the  troops  although  free  communcation  with  the  emi- 
grants was  permitted.^ 

In  this  year  a  most  interesting  outbreak  of  cholera  was  reported  by  the 
late  Surgeon  Charles  S.  Tripler,  U.  S.  A.,  and  I  regret  that  I  have  not 
space  to  reproduce  the  entire  report,  so  characteristic  is  it  of  all  work 
done  by  that  distinguished  officer.  Eight  companies  of  the  4th  U.  S.  In- 
fantry left  New  York  harbor,  July  5th,  on  the  steamship  Ohio,  for  Aspin- 
wall.  The  command,  including  women  and  children,  numbered  eight 
hundred.  During  the  voyage  a  number  of  cases  of  diarrhoea  occurred,  but 
when  the  steamer  reached  Aspinwall,  July  19th,  no  death  had  occurred. 
Cholera  Avas  epidemic  at  AspiuAvall  when  the  command  was  disembarked, 
and  it  was  epidemic  at  both  Cruces  and  Gorgona  on  the  route  across  the  Isth- 
mus. It  Avas  also  epidemic  among  the  laborers  on  the  railroad.  The  com- 
mand, for  AA'ant  of  transportation, Avas  delayed  at  Aspinwall  one  day;  the  next 
it  AA'as  transported  on  two  trains  to  the  terminus  of  the  railroad  at  Bara- 

J  Statement  of  Gen.  E.  A.  Carr,  U.  S.  A. 

^  Report  of  Acting  Asst.  Surgeon  N.  Spring,  U.  S.  A. 

3  Report  of  Asst.  Surgeon  G.  K.  Wood. 


THE   EPIDEMICS   OF   1848   TO   1857.  85 

coa.  At  that  point  it  was  determined  to  divide  the  command  into  two 
detachments,  the  main  body  to  be  transported  by  boat  on  the  Chagi-es 
river  to  Gorgona,  from  which  town  it  was  to  march  to  Panama.  The 
second  detachment  consisting  of  the  sick,  the  women  and  children,  one 
company  and  all  regimental  baggage  was  to  be  carried  by  boats  to  the  town 
of  Cruces,  where  they  would  be  provided  with  mule  transportation  to 
Panama.  Doctor  Tripler  was  ordered  to  accompany  the  last  detachment. 
July  18th  the  first  detachment  was  under  way  for  Panama;  that  day  the 
second  detachment  was  detained  at  Baracoa  on  account  of  the  non-arrival 
of  the  baggage,  but  the  next  day  it  proceeded  to  Cruces,  where  a  failure 
on  the  part  of  the  contractor  to  furnish  transportation  detained  the  de- 
tachment for  three  days.  At  Cruces  cholera  was  epidemic,  and  although 
every  exertion  Avas  made  to  save  the  detachment  from  the  infection,  the 
cupidity  of  the  contractor  condemued  them  to  three  days  of  inaction,  and 
on  July  20th  ^  the  disease  broke  out  in  the  command.  The  first  case  died 
after  an  illness  of  six  hours.  The  next  day  (July  21st)  the  detachment 
was  sent  forward,  but  notwithstanding  every  precaution  three  fatal  cases 
occurred  before  it  reached  Panama.  On  reaching  Panama,  Dr.  Tripler 
learned  that  the  main  body  of  the  troops  had  been  three  nights  on  the 
road  between  Clorgona  and  Panama  without  shelter;  that  they  had  been 
drenched  by  the  rain  every  day;  that  the  orders  in  regard  to  food  and 
drink  had  been  disregarded;  that  several  men  had  been  attacked  with 
cholera  and  had  died  on  the  way;  that  on  reaching  Panama  the  troops  had 
been  embarked  on  the  steamer  Golden  Gate,  then  lying  at  anchor  off  To- 
bago, twelve  miles  down  the  bay;  but  that  after  embarkation  fresh  cholera 
cases  had  occurred,  and  that  the  sick  liad  been  placed  on  a  "hulk"  an- 
chored near  by,  on  Avhich  a  cholera  hospital  had  been  improvised. 

A  delay  of  twenty-four  hours  Avas  experienced  at  Panama,  before  the 
men  of  the  second  detachment  could  join  the  main  body  on  the  Golden 
Gate.  The  hospital  on  the  "  hulk  "  was  continued,  and  to  it  all  suspicious 
cases  were  transferred  as  they  occurred. 

On  Tuesday,  July  27th,  the  disease  seemed  to  be  abating,  but  on  the 
evening  of  that  day  about  a  dozen  knapsacks  (which  had  Ijeen  left  on  the 
Isthmus)  were  received  on  board  the  steamer,  and  were  immediately  opened 
by  their  owners.  In  about  20  hours  all  of  these  men  were  taken  with 
cholera  in  its  Avorst  form,  and  most  of  them  died.  On  July  29th  the 
command  was  removed  from  the  steamer  and  placed  on  the  Island  of  Fla- 
mingo, about  six  miles  below  Panama.  The  last  case  on  the  steamer  oc- 
curred August  1st.  On  this  island  a  number  of  those  previously  ill  died, 
but  no  new  cases  occurred;  but  to  add  to  their  misfortune,  the  Chagres 
fever  appeared. 

On  the  3d  of  August  the  Golden  Gate  sailed  for  San  Francisco  with 
450  Avell  men,  the  officers  of  the  ship  refusing  to  receiA'e  any  who  Avere 
sick.  Doctor  Tripler  Avas  therefore  left  in  Flamingo,  with  all  the  sick, 
most  of  the  Avomen  and  children,  and  one  company  of  troops.  On  the 
8th  of  August,  this  party  Avas  received  on  the  steamer  Northerner  and 
sailed  for  San  Francisco,  leaving  four  cases  in  the  hospital  at  Tobago. 

On  the  Golden  Gate,  in  her  voyage  from  Panama  to  San  Francisco, 
there  were  ninety  cases  of  fever  and  diarrhoea,  Avith  three  deaths  among 

'  It  is  a  point  of  interest  tliat  Gen.  U.  S.  Grant,  then  the  regimental  quarter- 
master, AA^as  on  duty  in  this  detachment,  and  that  it  Avas  OA\-ing-  to  his  exertions 
that  the  detention  at  Cruces  Avas  not  prolonged. 


g6  ASIATIC  CHOLERA. 

the  troops.     On  the  Northerner  one  man  died  "  of  the  secondary  fever  of 
cholera. " 

The  only  cholera  record  I  can  find  of  the  disease  among  U.  S.  troops 
in  1853  is  at  Fort  Columbus,  Governor's  Island,  where  in  July  two  cases 
of  the  disease  are  reported,  both  recovering. 

In  1854,  cholera  was  epidemic  at  Jefferson  Barracks  from  March  to 
November.  The  number  of  cases  I  cannot  state,  but  the  mortality  is  re- 
ported as  one  in  three.  In  June  the'  disease  was  reported  at  Fort  Leaven- 
worth, but  in  a  modified  form.  At  Fort  Columbus,  Governor's  Island, 
there  were  two  distinct  outbreaks,  one  in  July,  when  thirty-eight  (38) 
cases  with  nine  (9)  deaths  occurred;  one  in  September  when  six  (6)  cases 
with  two  (2)  deaths  occurred.  At  Fort  Snelling,  Minn.,  one  fatal  case 
was  reported  in  the  person  of  a  recruit.  From  Forts  Kearny  and  Laramie 
reports  of  the  disease  still  existing  along  the  emigrant  roads  were  received. 

Cholera  was  again  reported  in  1855  at  Fort  Leavenworth  in  April,  and 
the  epidemic  infiuence  lasted  until  October.  One  hundred  and  fifteen 
(115)  cases  with  forty-seven  ( 47)  deaths  are  reported.  No  record  is  found 
of  the  ejiidemic  being  at  Jefferson  Barracks  in  this  year,  yet  the  presump- 
tion is  strong  that  the  epidemic  influence  remained  from  the  preceding  year, 
from  the  fact  that  in  April  cholera  broke  out  in  a  battalion  of  the  6th 
U.  S.  Infantry  en  route  from  Jefferson  Barracks  to  Fort  Kearny,  Ne- 
braska. In  this  command  the  disease  lasted  through  the  months  of  April, 
May  and  June. 

In  June  and  July  cholera  attacked  a  detachment  of  the  2d.  U.  8. 
Infantry  Avhich  was  ascending  the  Missouri  river  from  Fort  Leavenworth 
to  Fort  Pierre,  on  the  steamer  Arabia;  fifty-two  (52)  cases  occurred. 

In  July  cholera  appeared  at  Fort  Eiley,  Kansas;  this  post  was  at  the 
time  garrisoned  by  a  detachment  of  forty-seven  (47)  men  of  the  6th  U.-  S. 
Infantry;  but  several  hundred  quartermasters'  employees  were  engaged  in 
construction  of  the  fort.  Of  the  forty-seven  (47)  soldiers,  twent3^-one 
(21)  had  cholera  and  nine  (9)  deaths  occurred;  this  number  of  fatal  cases 
includes  one  officer.  The  disease  Avas  very  fatal  among  the  mechanics, 
who  fled  from  Riley  in  great  dismay  and  confusion.  I  am  informed  by  a 
distinguished  officer  of  the  army  that,  having  received  promotion  in  the  1st 
U.  S.  Calvary  (then  organized),  he  had  been  through  the  spring  of  1855 
recruiting  in  Georgia,  and  that  in  July  of  that  year  he  arrived  with  a  large 
detachment  of  recruits  at  Jefferson  Barracks.  These  recruits  were  from 
rural  districts  of  Georgia  and  Alabama.  They  were  perfectly  well  until  they 
reached  Nashville,  Tenn.,  where  they  were  placed  on  a  steamboat,  when 
they  were  taken  with  diarrhoea.  After  reaching  the  Mississippi  river, 
several  died  of  cholera,  and  several  other  deaths  occurred  after  arrival  at 
Jefferson  Barracks.  From  April  to  September,  a  few  cases  of  cholera 
were  reported  at  Baton  Eouge  Barracks,  La. 

The  persistence  of  cholera  in  an  epidemic  form  at  Jefferson  Barracks 
and  Fort  Leavenworth  in  1849,  1850,  1851,  1852,  1853,  1854  and  1855, 
if  indeed  those  posts  escaped  in  1848  and  1856,  is  to  be  found  in  the  fact 
that  Jefferson  Barracks  was  during  the  years  named  a  rendezvous  for 
troops  effecting  regimental  organization  or  changing  station,  and  that  Fort 
Leavenworth  was  a  general  depot  for  supplies,  as  well  as  a  rendezvous 
for  troops.  Both  posts  are  upon  river  banks,  both  liable  to  receive  infec- 
tion from  passing  steamers,  both  were  in  close  proximity  to  cities. 

On  Governor's  Island,  New  York  harbor,  where  cholera  had  been  epi- 
demic in  1849,  1852,  1853,  1854,  a  seemingly  isolated  outbreak  occurred 


THE  EPIDEMICS  OF   1848  TO   1857.  g7 

November,  1857,  and  was  confined  to  the  recruits  wlio  were  quartered  in 
Old  Castle  AVilliam.  The  late  Surgeon  C  II.  Lauh  reported  as  follows: 
"  The  Castle,  which  is  damp  and  ill- ventilated,  has  been  the  point  or  focus 
from  which  on  previous  occasions  the  disease  has  emanated,  and  when  the 
disease  appeared  this  time  the  sleeping  apartments  occupied  by  recruits 
Avere  overcrowded;  sometimes  as  a  matter  of  necessity  fifty  or  sixty  were 
occupymg  the  same  room." 


88 


ASL\TIC  CHOLERA. 


CHAPTEK  XIV. 

THE  EProEmC  OF  1866  IN  THE  UNITED  STATES  ARMY. 

In  1866,  the  depots  from  which  recruits  were  distributed  to  the  yarious 
regiments  were  Governor's  Island  in  New  York  harbor  and  Carlisle  Bar- 
racks in  Pennsylvania — Governor's  Island  for  the  infantry,  Carlisle  for 
the  cavalry  arms  of  the  service.  Recruits  reached  these  depots  after  en- 
listment had  been  accomplished  at  the  various  rendezvous;  the  rendezvous 
were  located  in  all  the  principal  cities  of  the  United  States,  and  in  that 
portion  of  those  cities  in  which  the  classes  from  which  recruits  for  the 
army  are  obtained  do  most  congregate.  A  recruit  at  either  rendezvous  or 
depot  is  not  deprived  of  his  liberty,  but  when  off  duty  is  permitted  to 
leave  the  confines  of  military  jurisdiction  at  the  pleasure  of  his  command- 
ing officer.  During  the  months  of  April,  May,  .June,  and  the  early  days 
of  July,  1866,  there  was  no  actual  reason  why  recruits  should  be  rigidly 
confined  to  Governor's  Island;  the  presumption  is  that  they  were  not  so 
confined,  but  that  they  had  mixed  Avith  their  fellows  in  both  New  York  and 
Brooklyn.  A  large  proportion  of  all  recruits  secured  for  the  army  are  of 
foreign  birth,  and  it  is  probable  that  among  the  nearly  four  thousand 
(4,000)  emigrants  who  arrived  at  New  York  during  the  months  of  April 
and  May,  1866,  on  cholera-infected  ships,  many  were  friends  of  newly  en- 
listed soldiers  on  Governor's  Island. 

On  the  3d  of  July,  two  (2)  cases  of  cholera  occurred  among  the  re- 
cruits on  Governor's"^ Island.  On  the  8th  of  July  cholera  broke  out  on 
Hart's  Island  in  recruits  who  had  been  sent  there  from  Governor's  Island. 
At  this  post  a  severe  epidemic  occurred,  and  the  garrison  was  removed  to 
David's  Island,  where  a  few  new  cases  occurred  among  the  troops  so  trans- 
ferred. One  case  occurred  at  Fort  Schuyler  in  the  person  of  an  officer 
who  had  slept  on  a  steamboat  used  the  day  before  in  transporting  the 
cholera-infected  command  between  Hart's  and  David's  Islands.  The  other 
garrisons  in  New  York  harbor  escaped,  nor  did  any  cases  occur  among 
enlisted  men  on  detached  duty  in  New  York  city.  The  total  number 
of  cases  reported  among  these  infected  troops  Avas  one  hundred  and  eighty- 
one  (181)  with  seventy-five  (75)  deaths. 

The  first  point  at  which  occurred  an  explosion  of  cholera,  icnown  to 
have  been  contracted  at  a  military  post  in  New  York  harbor,  was  Boston, 
Mass.,  Avhere,  on  the  19th  of  July,  a  soldier  who  had  been  on  duty  in 
the  cholera  hospital  died  at  the  Soldiers'  Rest. 

On  the  14th  of  July  the  steamship  San  Salvador  left  New  York  for 
Savannah,  Georgia,  with  seventy  (TO)  cabin  passengers,  sixty  (60)  in  crew 
and  steerage,  and  four  hundretl  and  seventy-six  (476)  recruits  for  the 
Seventh  U.  S.  Infantry.     The  troops  were  between  decks  and  much  over- 


THE  EPIDEMIC   OF   1866.  gQ 

crowded.  On  the  steamer  cholera  broke  out  among  the  enlisted  men,  and 
when  she  arrived  at  quarantine  below  the  city  of  Savannah,  on  the  18th, 
three  (3)  cases  had  died  and  twenty-five  (25)  were  under  treatment.  The 
troops  were  landed  on  Tybee  Island.  A  camp  and  hospital  were  estab- 
lished and  two  hundred  and  two  (202)  cases  of  cholera  with  one  hundred 
and  sixteen  (116)  deaths  occurred.  "  The  cabin  passengers  and  crew  of  the 
San  Salvador  appear  to  have  escaped,  but  of  the  ten  (10)  white  citizens 
residing  on  Tybee  Island  nine  (9)  Avere  seized  with  cholera  shortly  after 
the  arrival  of  the  San  Salvador  and  five  (5)  died.  The  tenth  fled  from  the 
island  and  is  reported  to  have  died  of  cholera  in  the  interior." 

No  cases  of  cholera  occurred  among  the  troops  stationed  in  Savannah, 
and  none  are  reported  as  occurring  among  citizens. 

Detachments  of  recruits  from  New  York  harbor  were  received  at  Jack- 
son Barracks,  New  Orleans,  La.,  on  July  8th  from  the  steamship  Mari- 
posa, on  July  16th  by  steamship  Livingston,  and  on  July  23d  from  Car- 
lisle Barracks  via  New  York  harbor  on  steamship  Merrimac.  At  quaran- 
tine station  below  New  Orleans,  two  or  three  sick  soldiers  had  been  taken 
from  the  Livingston;  one  case  died.  As  to  the  steamship  Mariposa  no 
record  can  be  found,  but  on  the  12th  of  July,  four  days  after  the  reported 
arrival  of  the  Mariposa,  cases  of  cholera  occurred  among  citizens  of  New 
Orleans.  The  steamer  Livingston  left  New  York  harbor  on  July  8th, 
having  on  board  a  detachment  of  five  hundred  and  nineteen  recruits  (519) 
from  Hart's  Islandall  in  good  health.  On  the  first  day  out  a  case  of  diarrhoea 
occurred  which  terminated  fatally  the  next  day.  On  the  seventh  day  out 
a  second  recruit  was  taken  with  cholera  and  died  in  a  few  hours.  On  July 
15th,  the  Livingston  reached  the  Mississippi  river  quarantine,  and  put  off 
two  recruits  sick  with  diarrhoea,  one  of  whom  died.  On  the  16th  of  July 
the  command  was  disembarked  at  Jackson  Barracks,  two  cases  of  cholera 
were  sent  to  hospital,  one  of  whom  died  with  choleraic  symptoms.  On 
the  29th  of  July  the  steamer  ]\Ierrimac  arrived  and  landed  some  two  hun- 
dred (200)  recruits  at  Jackson  Barracks. 

On  the  25th  of  July  a  case  of  cholera  occurred  at  Jackson  Barracks 
in  the  person  of  one  of  the  recruits  received  from  the  Livingston.  From 
this  date  the  disease  spread  rapidly  among  the  troops  at  Jackson  Barracks, 
and  in  the  city  of  New  Orleans;  it  is  reported  that  from  July  to  October 
31st,  one  thousand  one  hundred  and  eighty  (1,180)  deaths  occurred  among 
citizens,  and  one  hundred  and  seventy-three  (173)  deaths  among  the  U.  S. 
troops. 

(Cholera  was  carried  to  Forts  Jackson  and  St.  Philip  below  New  Orleans, 
on  the  river,  by  troops  returning  to  their  posts  after  the  riots  of  July  30th. 
The  first  case  occurred  August  10th,  and  was  followed  by  sixteen  (16)  cases 
and  eleven  (11)  deaths. 

August  3d,  cholera  developed  at  Greenville,  La.,  among  troops  return- 
ing from  duty  in  New  Orleans  during  the  riot.  August  17th,  cholera  was 
reported  among  the  troops  at  Baton  Kouge,  La. ,  and  during  the  next  two 
months  there  were  sixty-nine  (69)  cases  and  forty-three  (43)  deaths.  At 
Ship  Island,  Miss. ,  there  was  a  fatal  case  of  cholera  on  Sept.  8th,  which 
Avas  followed  by  other  cases,  among  military  convicts. 

September  22d  the  disease  appeared  at  Shreveport,  La.,  where  eleven 
(11)  cases  with  four  (4)  deaths  occurred  in  the  command.  From  the  city 
of  New  Orleans  cholera  was  carried  by  troops  into  the  State  of  Texas.  On 
the  19th  of  July  the  detachment  of  recruits  which  had  arrived  at  New 
Orleans  on  the  steamer  Livingston  from  New  York  harbor  were  embarked 


90  ASIATIC  CHOLERA. 

on  the  steamer  Texas  for  the  city  of  Galveston,  where  they  arrived  Jnly 
2"2d.  The  day  after  arrival  at  Galveston  a  recruit  was  taken  with  cholera 
and  died  in  thirty-six  hours,  and  in  the  ten  days  following  thirteen  (13) 
cases  occurred  among  these  recruits,  of  whom  six  (6)  died,  with  an  average 
duration  of  the  disease  of  about  eighteen  hours.'  The  disease  existed 
among  the  troops  at  Galveston  during  the  succeeding  month  (August) 
with  a  total  of  forty-four  (44)  cases  and  twenty-four  (24)  deaths. 

The  headquarters  of  the  department  of  Texas  being  at  Galveston,  the 
main  body  of  troops  and  recruits  who  arrived  at  that  city,  did  not  remain 
for  any  considerable  length  of  time,  but  were  speedily  forwarded  to  differ- 
ent regiments  and  posts.  At  the  distance  from  records  at  which  I  write 
I  am  unable  to  give  full  information  of  such  movements. 

The  history  of  the  two  hundred  (200)  cavalry  recruits  who  had  arrived 
at  New  Orleans  July  34th,  on  the  steamer  Merrimac,  must  now  be  followed 
out.  On  being  disembarked,  these  recruits  were  encamped  near  Jackson 
Barracks  for  a  few  days.  On  the  fourth  or  fifth  day  after  landing  a  case 
of  cholera,  which  proved  fatal,  occurred  among  them,  when  the  detachment 
was  promptly  forwarded  to  Texas.  They  were  placed  on  one  of  the  Mor- 
gan Gulf  line  steamers,  and  were  transported  to  Indianola,  Texas,  making 
a  stop  at  Galveston.  The  date  of  the  departure  of  this  detachment  from 
New  Orleans  was  probably  August  5th,  they  arrived  off  Galveston  probably 
on  August  8th,  and  the  disembarkation  at  Indianola  was  probably  August 
9th  or  lOtli.  I  am  informed  by  an  officer  who  accompanied  this  detach- 
ment from  Carlisle  Barracks,  Penn.,  to  San  Antonio,  Texas,  that  after 
arrival  at  Indianola  the  recruits  were  transferred  to  the  deck  of  a  schooner 
and  carried  to  Lavaca,  from  whence  they  were  transported  by  rail  to  Vic- 
toria, and  that  they  were  marched  from  the  latter  point  to  San  Antonio,  a 
distance  of  fifty  miles,  arriving  at  San  Antonio  probably  between  August 
19th  and  20tli,  and  although  no  cases  of  cholera  are  known  to  have  oc- 
curred among  them  after  leaving  New  Orleans,  diarrhoeas  were  prevalent. 

From  Galveston  cholera  was  carried  by  the  movement  of  recruits  to 
White's  Eanch  on  the  Rio  Grande,  where  it  occurred  August  13th;  to 
Brownsville,  August  20th;  to  Brazos  Santiago,  August  21st;  at  these  three 
(3)  posts  three  hundred  and  eleven  (311)  cases  with  one  hundred  and  forty- 
nine  (149)  deaths  occurred.  By  Mexican  freight  trains  cholera  was  carried 
from  the  Rio  Grande  to  San  Antonio,  where  the  first  case  occurred  at  the 
San  Juan  Mission,  six  miles  from  the  city,  on  the  2d  day  of  September 
in  a  person  who  had  just  arrived  in  one  of  these  trains  from  the  Rio  Grande. 

From  the  Mission  the  disease  was  carried  into  the  city  of  San  Antonio 
in  the  person  of  a  Mrs.  DeWitt,  who  had  been  taken  ill  at  the  first  stated 
point.  Other  cases  among  citizens  rapidly  followed,  and  an  epidemic  was 
established.  At  this  time  the  4th  U.  S.  Cavalry  and  a  detachment  of  the 
ITth  U.  S.  Infantry  were  stationed  at  San  Autonio.  These  troops,  so  soon 
as  the  epidemic  presence  was  known,  were  ordered  to  camp  upon  the 
Medina,  a  distance  of  twelve  miles  from  the  city.  Asst.  Surgeon  P.  V. 
Schenck  reports,  relating  to  the  4th  U.  S.  Cavalry:  '^The  time,  for  mov- 
ing proved,  pecnJiarhj  vnfortunate,  for  when  one-linlf  of  the  command  had 
moved,  a  flood  of  before  nnhea rd-of  severity  came,  causing  the  river  to  overflow 
the  camp  and  converting  that  which  had  heen  dry  into  a.  Jinge  mudhole.'^ 
In  this  condition  of  affairs  cholera  broke  out  in  the  camp  (September  7th) 
in  the  person  of  one  of  the  two  hundred  recruits  jiTst  before  received,  and 

1  Report  of  Surgeon  E.  P.  VoUum,  U.  S.  A. 


THE  EPIDEMIC   OF   1866.  91 

spread  with  great  rajiidity.  At  or  near  the  same  date  cholera  attacked 
that  portion  of  the  cavahy  regiment  that  was  in  San  Antonio.  So  soon 
as  the  roads  Ijecame  dry  enough  to  move,  these  companies  were  moved  to 
camp,  a  cholera  hospital  established,  and  every  effort  was  made  to  stamp 
out  the  disease.  The  greatest  mortality  was  reached  on  the  19tli  and  20th 
of  September  when  the  disease  rapidly  diminished,  and  on  the  close  of  the 
month  had  entirely  disappeared. 

On  the  15th  of  September  the  detachment  of  the  ITth  U.  S.  Infantry 
left  San  Antonio  for  camp  on  the  Medina;  up  to  that  date  no  cholera  had 
been  among  them,  although  they  had  been  surrounded  by  the  epidemic. 
This  camp  was  made  at  some  distance  from  the  cavalry  camp;  strict  non- 
intercourse  was  maintained,  and  every  sanitary  precaution  adopted;  Asst. 
Surgeon  W.  M.  Austin,  U.  S.  Army,  reports:."  I^otwithstanding,  cholera 
did  appear;  though  it  did  not  spread,  nor  last  long.  I  trace  its  origin  to 
the  fact  that  two  Mexican  teamsters  coming  from  the  town  stopped  one 
night  near  the  camp  and  died  from  cholera.  I  immediately  had  them  and 
their  effects  buried,  kindled  a  large  fire  on  spot  where  they  died,  and  disin- 
fected it;  a  sentry  kept  the  men  aAvay;  two  days  after,  cholera  appeared  in 
camp."  In  these  two  commands  three  hundred  and  eighty-seven  (387) 
cases  occurred  Avitli  sixty-four  (64)  deaths. 

The  epidemic  was  violent  in  San  Antonio.  Dr.  Austin  states  that 
those  unprejudiced  estimated  the  deaths  at  about  five  hundred,  and  that 
though  the  real  number  of  deaths  was  studiously  concealed,  it  was  known 
that  forty-five  permits  for  burial  were  issued  in  one  day,  Dr,  Schenck  esti- 
mates the  deaths  at  nearly  six  hundred  in  a  population  greatly  diminished 
by  those  that  fled.  He  gives  an  interesting  account  of  a  Roman  Catholic 
College  in  the  center  of  the  city  which  was  filled  with  students,  who  closed 
their  doors  and  allowed  no  one  to  enter  or  depart,  and  who  escaped  the 
disease  entirely. 

At  Indianola,  cholera  became  epidemic  about  September  5th,  I  am 
not  able  to  record  all  the  arrivals  of  recruits  and  of  troops  at  this  point 
during  the  year;  but  a  point  of  interest  has  come  to  my  knowledge  in  re- 
lation to  the  two  hundred  cavalry  recruits  from  New  Orleans,  I  am  in- 
formed by  the  officer  before  referred  to,  who  accompanied  this  detachment, 
that  when  they  were  landed  from  the  Xew  Orleans  steamer  no  supply  of 
drinking  water  had  been  obtained  for  the  command,  and  that  they,  suffering 
extremely  from  thirst,  had  been  allowed  to  leave  camp  and  obtain  water 
for  themselves.     These  recruits  probably  visited  all  portions  of  the  town. 

In  September  a  detachment  of  one  hundred  recruits  for  the  5th  U,  S, 
Cavalry,  then  stationed  at  Austin,  Texas,  arrived  at  Indianola,  where  they 
were  attacked  with  cholera.  They  were  marched  out  of  town  at  once,  but 
before  reaching  Austin,  ten  (10)  deaths  occurred.  When  a  few  miles 
from  the  city  they  were  quarantined,  but  this  quarantine  was  reported  by 
Assistant  Surgeon  Bacon,  U.  S.  A,,  as  "imperfect."  Seven  (7)  deaths, 
occurred  and  soon  after  the  arrival  of  this  detachment  two  (2)  fatal  cases 
occurred  among  the  troops  in  the  city;  but  the  disease  died  with  them  and 
no  new  cases  occurred  until  the  following  November,  when  ten  (10)  cases 
occurred,  all  of  which  were  fatal. 

The  movements  of  other  bodies  of  recruits  from  New  York  harbor 
requires  some  consideration.  It  has  been  stated  that  during  this  epidemic 
one  hundred  and  eighty-one  (ISl)  cholera  cases  wdth  seventy-eight  (78) 
deaths  had  occurred  on  Governor's,  Hart's  and  David's  Islands,  New  York 
harbor.     These  cholera  cases  were,  however,  accompanied,  at  the  three  (3) 


92  ASIATIC  CHOLERA. 

posts  at  wliicli  they  occurred,  by  forty-nine  (49)  cases  of  cholera  morlnis, 
among  whom  no  deaths  occurred,  and  one  thousand  one  hundred  and  fifty- 
six  (1,156)  cases  of  acute  diarrhoea  among  whom  one  (1)  death  was  reported; 
and  it  is  not  unreasonable  to  suppose  that  through  the  dejecta  of  persons 
suffering  from  acute  diarrhoea  the  area  of  epidemic  influence  was  extended. 

A  detachment  of  one  hundred  and  forty-five  (1J5)  recruits  arrived  at 
Vicksburg,  Miss.,  from  Governor's  Island  on  the  11th  of  July.  August 
21st  a  barber  employed  among  the  troops  died  of  cholera;  the  next  day 
(22d)  two  fatal  cases  occurred  in  the  command  and  fifty-nine  (59)  cases 
of  cholera  with  twenty-five  (25)  deaths  followed.  July  ITtli  a  detachment 
of  fifty-one  (51)  recruits  from  Governor's  Island  arrived  at  Jackson,  Miss. 
In  this  command  during  August  and  September  there  were  eight  (8) 
cholera  cases  and  six  (6)  deaths.  During  the  five  months  ending  with  De- 
cember, 213  cases  of  acute  diarrhoea,  occurred  with  two  deaths. 

From  the  16th  to  19th  days  of  July,  detachments  of  recruits  from 
Governor's  Island  amounting  to  three  hundred  and  sixty-four  (36-4)  men 
arrived  at  the  U.  S.  Barracks  in  the  city  of  Louisville,  Ky.  On  arrival 
diarrhoeas  prevailed  among  them.  A  fatal  case  of  cholera  in  the  person  of 
a  recruit  occurred  July  29th,  followed  by  two  fatal  cases  on  the  31st, 
thirty-six  (36)  cases  with  twenty-three  (23)  deaths  in  all.  It  was  reported 
that  more  than  50  per  cent,  of  the  cases  were  from  one  company  which  was 
chiefly  composed  of  recruits.  Eeports  at  the  time  divided  the  command 
for  purposes  of  observation  into  three  classes,  viz:  I.  Old  soldiers;  II.  Ee- 
cruits  who  had  enlisted  at  Louisville;  III.  Eecruits  received  from  New 
York  Harbor.  And  it  was  determined  that  the  New  York  recruits  had 
suffered  most  severely,  the  post  recruits  less,  and  that  the  old  soldiers  had 
suffered  but  slightly.  During  July,  August  and  September  two  hundred 
and  twenty-one  (221)  cases  of  acute  diarrhcjea  occurred  in  this  command. 

On  the  31st  of  August  the  company,  in  which  it  is  reported  that  more 
than  50  per  cent,  of  the  Taylor  Barracks  cases  of  cholera  had  occurred,  was 
ordered  to  Bowling  Green,  Ky.  On  departure,  this  company  left  six  (6) 
cholera  cases  in  the  post  hospital.  After  arrival  at  Bowling  Green  and 
within  the  first  three  days,  six  (6)  cases  occurred,  followed  by  two  (2) 
other  cases  in  month  of  November;  all  recovered.  In  this  command  there 
were  sixteen  cases  of  acute  diarrhoea. 

A  most  interesting  local  epidemic  is  to  be  found  in  the  history  of  the 
56th  U.  S.  Colored  Infantry,  which  regiment,  until  the  ?th  of  August, 
had  been  stationed  at  Helena  and  Duvall's  Bluff',  Arkansas.  Being  ordered 
to  St.  Louis,  Missouri,  they  moved  in  two  detachments  from  Helena. 
Five  (5)  companies  that  had  been  stationed  at  Duvall's  Bluff',  on  White 
river,  Avere  embarked  August  9th  on  the  Mississippi  river  steamer  Con- 
tinental. The  regimental  headquarters  and  remaining  five  (5)  com- 
panies following  on  August  10th  on  the  steamer  Platte  Yalley.  A  spe- 
cial inspection  of  the  post  of  Duvall's  Bluff  made  by  the  Medical  Director 
of  the  Department  of  Arkansas  on  the  1st  of  September  failed  to  discover 
the  presence  of  cholera  there,  although  it  had  been  reported  that  fatal  cases 
had  occurred  on  steamboats  plying  the  White  river.  The  disease  did  not 
appear  at  Helena  until  August  30tli,  therefore  this  regiment  at  the  date 
of  embarkation  on  the  steamers  Continental  and  Platte  \'alley  were  most 
probably  free  from  cholera  infection.  The  regimental  commander  re- 
ported that  both  boats  were  large  and  had  the  usual  accommodations,  and 
that  the  command  had  been  unusually  healthy  during  the  summer. 
Cholera  broke  out  on  the  Continental  shortly  after  leaving  Helena;    one 


THE  EPIDEMIC  OF   186C.  93 

case  "svas  put  ashore  at  ^Mempliis,  Tenn.  (case  of  August  15),  and  when  slie 
reached  Cairo,  111.,  she  had  on  hoard  thirteen  (lo)  cholera  dead  and  about 
sixty  cases  (60)  under  treatment.  The  steamer  proceeded  to  quarantine 
grounds  below  Jefferson  Barracks,  Mo.,  where  the  troops  were  disem- 
barked and  a  cholera  hospital  established.  About  twenty-four  hours  after 
leaving  Helena  a  death  occurred  on  the  Platte  Valley,  which,  there 
being  no  medical  officer  on  board,  was  supposed  to  be  from  a  congestive 
chill ;  and  a  similar  case  occurred  on  the  boat  between  Cairo  and  St.  Louis. 
During  this  time  some  fifty  odd  men  of  this  command  were  taken  sick 
from  various  diseases.  At  Cairo  a  physician  had  been  engaged  to  accom- 
pany the  boat  to  8t.  Louis.  On  arriving  at  quarantine  grounds,  a  careful 
inspection  of  the  troops,  passengers  and  crew  of  the  Platte  Valley  was 
made,  but  no  cholera  was  found.  She  then  proceeded  to  the  city  of  St. 
Louis,  where  she  arrived  at  midnight  of  the  13th.  The  command  was  kept 
on  board.  Early  the  next  morning  the  medical  officer  reported  a  case  of 
cholera.  The  Platte  Valley  was  ordered  at  once  to  quarantine  grounds, 
the  troops  disembarked  and  a  camp  formed,  which  was  kept  distinct  from 
the  camp  of  the  troops  who  arrived  on  the  Continental.  At  this  camp 
cholera  raged  during  the  remainder  of  August  and  through  September. 
In  the  command  numbering  six  hundred  and  twenty-three  (623)  men, 
two  hundred  and  fifty-six  (256)  cases  and  one  hundred  and  thirty-nine 
(139)  deaths  occurred,  and  this  number  of  deaths  does  not  include  those 
Avho  died  on  the  river  before  reaching  quarantine  grounds  below  Jefferson 
Barracks.  While  the  epidemic  lasted  two  hundred  and  thirty-four  (234) 
cases  of  acute  diarrhcea  were  treated  in  the  camp.  A  more  marked  in- 
stance of  the  agency  of  common  carriers  in  the  diffusion  of  disease  can 
scarcely  be  found.  Both  the  Continental  and  the  Platte  Valley  were 
steamers  in  the  New  Orleans  trade,  both  were  bound  up  the  river  from 
below  Helena,  where  this  most  unfortunate  command  was  embarked  upon 
them.  When  marched  aboard  these  steamers,  the  troops  were  absolutely 
free  from  cholera;  when  they  were  disembarked,  cholera  had  infected  the 
whole  regiment. 

To  a  limited  extent  cholera  spread  among  the  garrison  of  Jefferson 
Barracks  in  the  months  of  August  and  September.  In  August,  with  a 
command  of  two  hundred  and  eighty-four  (284)  mean  strength  there  oc- 
curred six  (6)  cases  of  cholera  and  five  (5)  deaths.  In  September  the  mean 
strength  of  the  command  was  three  hundred  and  forty-four  (344) ;  there 
were  two  (2)  cases  both  of  which  were  fatal.  During  both  months  the 
number  of  cases  of  acute  diarrhoea  was  very  large,  being  one  hundred  and 
three  (103)  in  each  month,  with  no  deaths. 

It  is  not  positively  known  how  cholera  reached  the  city  of  St.  Louis 
in  1866,  and  at  this  late  date  it  seems  impracticable  to  arrive  at  a  solution 
of  the  problem.  The  diffusion  could  not  have  been  by  the  steamer  Platte 
Valley,  for  she  arrived  August  13th,  whereas  the  disease  was  in  the  city  as 
early  as  July  27th,  according  to  one  authority  and  not  later  than  August 
3d  by  the  most  recent  (Mr.  Robert  Moore  of  St.  Louis). 

Four  (4)  cholera  cases  with  three  (3)  deaths  occurred  during  the  months 
of  August  and  September  in  the  Ordnance  detachment  at  the  St.  Louis 
arsenal,  the  first  fatal  case  occurring  August  ITth. 

In  the  history  of  the  cholera  epidemic  of  1873  in  the  United  States,  on 

'  That  Jeflferson  Barracks  escaped  a  severe  visitation  of  cholera  in  1866  was 
mainly  due  to  the  thorough  sanitary  management  of  Col.  E.  Swift,  Surgeon  U.  S. 
A.,  tlien  post  surgeon. 


94 


ASIATIC  CHOLERA. 


page  672,  I  made  the  statement  that  "  during  the  epidemic  St.  Louis  lost 
eight  thousand  five  hundred  (8,500)  cases."  A  recent  investigation  of  the 
records  of  this  epidemic  as  it  aifected  St.  Louis,  by  Mr.  John  Moore  (in 
which  he  was  able  to  use  records  inaccessible  to  me  when  my  investigation 
was  made,  ten  years  ago),  shows  that  the  total  number  of  fatal  cases  in 
that  city  was  "three  thousand  five  hundred  and  twenty-seven  (3,527)." 
This  statement  is  based  upon  two  independent  examinations — one  made  by 
the  board  of  health  during  the  occurrence  of  the  epidemic,  the  other  by 
a  house-to-house  inquiry  by  the  city  assessors  after  the  subsidence  of  the 
epidemic. 

After  a  careful  consideration  of  all  the  circumstances,  I  am  more  than 
willing  to  accept  the  accuracy  of  the  enumeration  of  Mr.  Moore.  The 
few  facts  which  I  was  able  to  furnish  were  laboriously  obtained.  My  enu- 
meration was  taken  from  newspaper  reports,  where  all  totals  were  expressed 
in  numerals,  and  it  is  very  easy  to  understand  how  3,500  could  be  so 
printed  as  to  represent  to  the  eye  8,500. 

During  the  months  of  August  and  September,  a  serious  outbreak  of 
cholera  occurred  among  the  troops  stationed  at  Richmond,  Virginia.  In 
a  command  of  about  fifteen  hundred  (1,500)  men,  two  hundred  and 
seventy-one  (271)  cases  with  one  hundred  and  three  (103)  deaths  occurred. 
The  first  case  was  on  August  12th,  in  the  person  of  a  soldier  who  had 
spent  the  previous  night  in  a  debauch  in  the  city.  On  the  13th,  four  men 
from  the  same  company  as  the  first  case  were  attacked.  These  five  men 
had  been  in  together  on  the  debauch  of  the  night  of  August  11th.  Dur- 
ing the  two  succeeding  days  ten  new  cases  Avere  admitted  to  hospital,  eight 
of  whom  were  from  the  same  company.  While  cholera  was  epidemic  five 
hundred  and  ninety-two  (592)  cases  of  acute  diarrhoea  were  treated. 

During  the  months  of  July  and  August  recruits  had  been  received  from 
!ts  ewport  Barracks,  Ky. ,  and  from  New  York  harbor.  The  disease  was 
carried  by  companies  of  troops  from  Eichmond  to  Fortress  Monroe,  Nor- 
folk and  Yorktown,  Va.,  but  did  not  spread. 

The  only  eastern  point  left  unnoticed  which  had  been  designated  as  a 
focus  for  cholera  in  the  army,  is  Carlisle  Barracks  in  Pennsylvania.  It  is 
certainly  unjust  to  apply  such  a  designation  to  Carlisle.  It  was  the  depot 
for  cavalry  recruits,  and  during  1866  cavalry  recruits  were  certainly  agents 
in  the  diffusion  of  cholera;  but  thej  certainly  did  not  convey  that  infection 
from  the  depot,  but  it  was  communicated  to  them  after  they  had  been 
sent  forward  to  their  regiments.  It  has  already  been  shown  how  a  body  of 
two  hundred  cavalry  recruits  were  sent  to  New  York  harbor  for  trans- 
portation to  Texas  while  cholera  was  existing  on  Governor's,  Hart's  and 
David's  Islands.  It  has  been  shown  that  these  recruits  reached  Jackson 
Barracks,  Louisiana,  after  cholera  had  been  epidemic  in  New  Orleans, 
that  one  fatal  case  had  occurred  among  them  while  at  Jackson  Barracks, 
but  that  no  other  cases  can  be  found  among  their  numbers  until  they  were 
in  San  Antonio,  Texas,  and  the  cavalry  camp  on  the  Medina  twelve  miles 
from  that  city.  It  is  true  that  the  first  cases  in  the  4th  U.  S.  Cavalry 
were  among  their  number,  but  cholera  had  been  epidemic  in  San  Antonio 
for  some  days  before  they  were  attacked. 

Surely  nothing  animate  or  inanimate  at  the  cavalry  depot  had  any 
agency  in  that  dift\ision.  The  cholera  history  of  Carlisle  Barracks  in  1866, 
is  simply  this:  On  the  12th  of  August  a  death  from  cholera  occurred 
and  was  followed  by  a  second  fatal  case  on  the  20th.  One  of  the  hospital 
attendants  on  these  cases  Avas  taken  with  the  disease  but  recovered.     The 


THE   EPIDEMIC   OF   186(3. 


95 


two  fatal  cases  were  recruits  received  from  tlie  Philadelphia  rendezvous, 
and  had  been  at  depot  not  over  thirty-six  hours  (in  either  case)  when  they 
were  sent  to  hospital  ill  with  cholera. 

According  to  the  statement  of  the  chief  clerk  of  the  Philadelphia  health 
office  there  had  been  thirty-one  (31)  deaths  from  cholera  in  the  city  of 
Phihtdelphia  in  the  month  of  July,  and  two  hundred  and  forty-six  ("246) 
in  the  month  of  August,  the  month  in  which  these  two  recruits  were  en- 
listed. In  September  two  men  of  the  permanent  company  had  non-fatal 
cases  of  cholera,  immediately  after  their  return  from  Jefferson  Barracks, 
Missouri,  where  they  had  been  as  a  part  of  guard  on  duty  with  a  detach- 
ment of  recruits  sent  from  the  depot.  It  will  be  remembered  that  cholera 
existed  at  Jefferson  Barracks,  and  at  the  quarantine  camp  below  those 
barracks,  in  that  month.  To  reach  Jefferson  Barracks  from  Carlisle  and 
to  return  to  their  station  necessitated  two  distinct  visits  to  the  city  of  St. 
Louis  by  this  guard.  At  the  time  of  their  visits  cholera  was  virulent  in 
those  portions  of  St.  Louis  which  soldiers,  for  even  a  short  time  off  duty, 
would  frequent.  It  is  stated  in  the  Medical  Kecord  of  September  15th,  18G6 : 
"  We  find  that  St.  Louis  has  been  the  heaviest  loser  in  the  Southwest, 
having  already  published  a  death-list  approaching  in  round  numbers  nearly 
two  thousand  five  hundred  (2,500)  as  the  result  of  a  month's  prevalence 
of  the  epidemic  in  a  very  virulent  form."  A  sixth  case  occurred  at  Carlisle 
October  17th,  in  the  person  of  a  recruit  who  had  arrived  the  previous  day 
from  the  Chicago  rendezvous  (cholera  being  epidemic  in  Chicago)  and 
terminated  fatally  on  the  18th.  In  the  person  of  the  Avife  of  a  soldier 
another  fatal  case  occurred  at  the  depot.  This  woman  had  been  in  Roch- 
ester, N.  Y. ,  and  was  attacked  with  cholera  shortly  after  her  arrival  at  the 
barracks.  From  August  to  September  inclusive  eighty-six  (86)  cases  of 
acute  diarrhoea  were  treated. 

On  the  25tli  of  August,  three  hundred  and  eighty-four  (384)  cavalry 
recruits  from  Clarlisle  Barracks  arrived  at  Fort  Riley,  Kansas.  They  had 
come  by  way  of  St.  Louis.  On  the  30th  of  August,  a  cholera  death  oc- 
curred among  these  recruits.  The  disease  was  confined  exclusively  to 
them,  and  did  not  spread  to  other  troops  at  the  post.  Fifty-nine  (59) 
cases  of  the  disease  with  twenty-seven  (27)  deaths  occurred,  but  from 
August  to  December  (inclusive)  G35  cases  of  diarrhoea  were  treated  in  the 
garrison. 

At  Fort  Leavenworth,  Kansas,  the  first  case  of  cholera  occurred  Sep- 
tember 18th.  The  patient  died  the  next  day.  Altogether  there  were 
seven  (7)  cases  with  five  (5)  deaths  at  this  post.  From  September  to 
December  inclusive  292  cases  of  diarrhcea  (acute)  were  treated.  These 
cases  all  occurred  among  troops  recently  arrived  from  other  stations.  The 
city  of  Leavenworth,  two  miles  south  of  the  post,  was  infected,  but  only 
about  twenty  (20)  cases  were  reported. 

On  the  2btli  of  November,  a  detachment  of  three  hundred  and  fifty- 
six  (35G)  recruits  sailed  from  New  York  harbor  en  route  for  California. 
They  reached  San  Juan  del  Norte,  Nicaragua,  December  8th,  but  on  ac- 
count of  a  rough  sea  they  were  not  landed  until  the  15th.  On  the  morn- 
ing of  the  16th  the  troops  were  placed  on  a  steamer  and  proceeded  up  the 
San  Juan  river.  The  command  up  to  this  time  was  in  perfect  health. 
No  communication  was  allowed  with  the  shore.  At  9  o'clock  a.m.  of  the 
16th,  a  soldier  was  taken  with  cholera  and  died  the  same  day.  At  daylight 
of  the  17th,  five  (5)  other  cases  were  buried.  On  the  17th  there  Avere  four 
(4)  cholera   deaths;    on  the   18th   three  (3),  and  on  the    19th  two  (2). 


96  ASIATIC  CHOLERA. 

Reaching  La  Virgin,  on  Lake  Xicaragua,  a  camp  was  made,  as  the  command 
was  obhged  to  await  the  arrival  of  a  steamer  on  the  Pacific.  In  this  com- 
mand fifty-four  (54)  cases  Avith  twenty-seven  ('37)  deaths  occurred.  There 
was  no  cholera  at  San  Juan  when  the  troops  landed;  hut,  simultaneously 
with  the  outbreak  among  the  troops,  the  passengers  and  native  boatmen 
on  another  steamer  were  attacked.  There  had  been  no  communication 
between  these  two  boats,  and  the  native  boatmen  on  the  passenger  steamer 
had  not  been  within  two  miles  of  the  troops.  The  medical  officer  was 
confident  that  he  had  traced  the  epidemic  to  certain  baggage  which  had  been 
landed  from  the  steamer  at  San  Juan.  This  local  epidemic  on  the  shore  of 
Lake  Nicaragua  Avas,  it  is  believed,  the  last  in  which  the  disease  could  be 
traced  back  to  depots  in  New  York  harbor. 

A  second  focus  from  which  cholera  was  diffused  was  established  at 
Newport  Barracks,  Kentucky.  Eecruits  were  received  at  this  point  from 
Governor's  Island  during  the  continuance  of  the  epidemic.  But  they  were 
also  received  from  rendezvous  in  cities  where  cholera  was  epidemic.  They 
came  from  Detroit,  at  which  city  on  the  29th  of  May,  cholera  deaths  had 
occurred  among  emigrants;  from  Philadelphia,  where  the  inception  of  the 
epidemic  was  on  the  25th  of  April;  from  Cincinnati,  almost  daily  from 
July  loth  to  August  12th;  from  St.  Louis,  where  cholera  appeared  in  the 
week  ending  August  3d,  in  frequent  detachments;  and  from  Chicago, 
where  cholera  appeared  about  July  21st,  in  the  person  of  an  emigrant. 

On  the  10th  of  July  a  detachment  of  recruits  from  (lovernor's  Island 
arrived  at  Newport  Barracks.  No  case  of  cholera  occurred  among  them; 
but  the  day  after  their  arrival  (July  lltli)  a  German  woman  Avho  had 
accompanied  these  recruits  died  at  Cincinnati  on  the  opposite  bank  of  the 
Ohio  river,  in  a  filthy  tenement  house.  No  cholera  case  occurred  at  this 
depot  .until  August  12th  when  a  recruit  doing  duty  as  a  teamster,- and 
Avho  had  been  daily  in  Cincinnati,  died  of  cholera.  Nine  (9)  cases  of 
cholera  folloAved  Avith  five  (5)  deaths.  From  August  to  December  (inclu- 
sive) one  hundred  and  three  (103)  cases  of  acute  diarrhoea  Avere  treated, 
Avith  no  deaths. 

About  the  last  of  August  or  first  of  September,  three  hundred  and 
sixty  (360)  recruits  from  NcAvport  Barracks  arrived  at  Nashville,  Tennes- 
see, and  Avent  into  quarters  near  the  Cumberland  hospital.  On  the  2d 
of  September  three  cholera  cases  occurred  among  these  recruits;  one  case 
Avas  fatal.  About  the  same  time  the  disease  became  epidemic  in  the  city 
of  Nashville,  but  in  no  AA'ay  traceable  to  the  movement  of  these  recruits. 
Seventy- two  (72)  cases  and  forty-one  (41)  deaths  occurred. 

A  recruit  from  Nashville  Avas  taken  sick  in  quarters  at  Memphis,  Tenn., 
with  cholera,  on  September  6th,  and  died  the  next  day.  This  case  Avas 
folloAved  by  tAventy-one  (21)  cases  Avith  sixteen  (16)  deaths  among  the 
troops;  and  one  hundred  and  ten  (110)  cases  of  acute  diarrhcea.  A  case 
had  been  landed  from  a  river  steamer  on  the  15th  of  August,  and  had 
died  in  the  post  hospital.  The  local  epidemic  in  Memphis  Avas  not,  hoAV- 
ever,  occasioned  by  the  arrival  of  these  recruits. 

The  first  fatal  case  at  Little  Rock  Barracks  occurred  September  12th, 
and  Avas  folloAved  by  one  hundred  and  thirty-eight  (138)  cases  Avitli  sixty- 
six  (66)  deaths;  Avith  one  hundred  and  fifty-eight  (158)  cases  of  simple 
diarrhoea.  Recruits  from  Newport  Barracks  had  arrived  on  the  15th  of 
August,  but  it  is  not  probable  they  were  factors  in  the  epidemic.  It  is 
presumable  that  the  disease  was  carried  from  Memphis,  Tenn. ,  by  Arkan- 
sas river  steamers  to  Little  Rock,  and  that  the  troops  received  the  infection 


THE  EPIDEMIC  OF    1866  97 

from  that  city.  The  epidemic  at  this  point  was  much  more  intense  among 
the  troops  than  it  was  among  the  citizens  of  the  town.  From  Little  Rock^,. 
cholera  was  conveyed  by  river  steamers  to  Fort  Smith,  Arkansas.  Twelve 
(12)  cases  with  four  (4)  deaths  occurred,  with  one  hundred  and  ten  (110) 
cases  of  acute  diarrhoea.  At  this  point  the  epidemic  was  more  severe 
among  the  citizens.  According  to  the  statement  of  Doctor  Duval  three 
hundred  (300)  cases  were  treated;  the  number  of  deaths  was  not  reported. 

At  Fort  Gibson,  Cherokee  Nation,  a  company  of  troops  from  Fort 
Smith,  en  route  to  Fort  Riley,  Kansas,  arrived  October  12th.  Cholera 
prevailed  at  Fort  Smith  at  the  time  of  departure  of  the  company.  Three 
days  after  their  arrival  at  Fort  Gibson,  two  fatal  cases  of  cholera  occurred 
in  that  company.  The  soldier  who  acted  as  nurse  was  attacked  but  re- 
covered. One  other  fatal  case  occurred  during  the  mouth  of  Novem- 
ber— a  total  of  four  (4)  cases  with  three  (3)  deaths — and  fourteen  (14) 
cases  of  acute  diarrhoea. 

A  detachment  of  recruits  was  sent  from  Newport  Barracks  (via  Nash- 
ville, Tenn.)  to  Atlanta,  Georgia,  for  assignment  to  companies.  They 
arrived  at  Atlanta  on  September  9th,  bringing  with  them  two  cases  who 
developed  cholera  at  Chattanooga,  Tenn.  Nineteen  (19)  cases  with  seven 
(7)  deaths,  and  ten  (10)  cases  of  acute  diarrhoea,  followed. 

At  Augusta,  Georgia,  the  disease  appeared  September  9th  in  the  per- 
sons of  recruits  on  the  way  to  their  companies.  There  were  eight  (8)  cases 
Avith  seven  (7)  deaths  and  fifty-six  cases  of  acute  diarrhoea. 

The  last  record  of  cholera  diffusion  by  recruits  from  Newport  Barracks 
is  at  Helena,  Arkansas,  on  the  30tli  of  August.  During  August  and  Sep- 
tember there  were  ten  (10)  cases  of  cholera,  Avitli  six  (6)  deaths;  and  ten 
(10)  cases  of  simple  diarrhoea.  A  detachment  of  twenty-eight  (28)  recruits 
had  been  received  at  this  post  on  the  3d  of  August.  They  are  supposed 
to  have  been  a  portion  of  a  detachment  of  recruits  which  left  Newport 
Barracks,  Kentucky,  for  Little  Rock,  July  28th. 

In  all  military  commands  sanitary  regulations  Avere  strictly  enforced, 
and  the  influence  of  such  measures,  in  the  majority  of  instances,  was 
marked  in  either  arresting  or  stamping  out  the  epidemic.  This  is  notably 
the  case  in  the  military  posts  in  New  York  harbor,  in  the  immediate 
vicinity  of  a  cholera-infected  city,  and  in  a  harbor  into  which  cholera-in- 
fected ships  were  constantly  arriving  from  April  18th  to  November  28th. 
Originating  in  the  person  of  a  recruit  on  Governor's  Island,  the  disease 
was  conveyed  in  turn  to  Hart's  and  David's  Islands.  But  at  these  three 
points  the  epidemic  was  confined  by  a  cordon  de  sante,  so  far  as  sur- 
rounding posts  were  concerned.  A  single  non-fatal  case  occurred  at  Fort 
Schuyler  after  contact  with  an  infected  steamboat,  but  at  four  other 
harbor  posts  no  cases  occurred.  From  New  York  harbor  cholera  was. 
carried  to  Tybee  Island;  below  the  city  of  Savannah,  but  the  disease  was 
confined  to  the  island;  to  New  Orleans,  Louisiana,  where  owing  to  the 
movements  of  emigrants  it  is  impossible  to  determine  whether  the  infec- 
tion was  due  to  the  arrival  of  troops.  The  turmoil  of  political  affairs  in 
New  Orleans  demanded  the  presence  of  troops  in  all  portions  of  the  city, 
which  at  that  time  was  in  an  uncleanly  condition — every  essential  for 
the  rapid  propagation  of  the  specific  cholera  poison  was  present,  and 
cholera  was  carried  to  all  military  stations  in  the  State.  From  New 
Orleans  cholera  was  carried  by  troops  to  the  State  of  Texas,  arriving  at 
Galveston  and  Indianola.  Here  the  infection  conveyed  by  troops  joined 
the  stream  of  infection  conveyed  by  emigrants,  and  cholera  overran  the 

7 


9g  ASIATIC  CHOLERA. 

State;  and  at  military  posts,  having  but  a  brief  duration  although  costing 
many  valuable  lives.  At  New  Orleans  the  steamers  on  the  Mississippi 
river  becoming  infected,  they  in  turn  distributed  the  disease  to  troops 
when  in  transit.  From  New  York  harbor  recruits  were  sent  to  Richmond, 
Virginia,  where  they  were  taken  with  the  cholera,  but  it  remains  in  doubt 
if  the  epidemic  among  the  troops  stationed  at  that  point  was  due  to  the 
arrival  of  these  recruits,  or  from  contact  with  the  cholera  germ  among 
the  citizens  of  that  city.  From  Richmond  troops  carried  cholera  to  York- 
town,  Fortress  Monroe  and  Norfolk,  Virginia,  but  no  diffusion  occurred. 
From  New  Y^ork  cholera  was  taken  by  recruits  to  Louisville,  Ky.,  and 
was  carried  by  troops  from  Louisville  to  Bowling  Green,  Ky. 

The  recruits  at  Newport  Barracks,  Ky.,  received  the  cholera  infection 
from  rendezvous  in  the  cities  of  Cincinnati,  Ohio;  Chicago,  Illinois,  and 
St.  Louis,  Missouri.  What  agency  the  movements  of  recruits  may  have 
had  in  infecting  the  city  of  Cincinnati  cannot  be  determined.  If  the 
fact  can  be  fully  received  that  the  cholera  death  in  that  city  of  July  11th 
was  in  the  person  of  a  woman  who  had  accompanied  a  detachment  of 
recruits  from  New  York  harbor,  the  agency  must  be  admitted. 

From  Newport  Barracks  cholera  was  carried  by  recruits  to  Nashville 
and  Memphis,  Tennessee;  and  to  Atlanta  and  Augusta,  Georgia.  At 
Nashville  the  line  of  cholera  infection  joined  that  ascending  the  Mississippi 
river;  and  successively  Little  Rock,  Fort  Smith,  Fort  Gibson,  Helena, 
Jefferson  Barracks,  and  perhaps  St.  Louis,  were  infected. 

From  New  Y^ork  harbor,  cholera  infection  was  undoubtedly  carried 
by  cholera-infected  baggage  to  the  San  Juan  river,  Nicaragua;  and  as 
a  result  a  cholera  hospital  for  U.  S.  troops  was  established  on  the  shores 
of  Lake  Nicaragua. 

As  a  contrast  to  the  story  of  cholera  diffusion  in  1866,  and  as  an 
unanswerable  argument  to  those  who  assert  that  this  disease  has  established 
itself  in  the  valley  of  the  Mississippi  and  Ohio  rivers,  and  who  teach  that 
as  the  Delta  of  the  Ganges  is  the  habitat  of  cholera,  so  is  the  Delta  of  the 
Mississippi,  a  few  paragraphs  from  my  cholera  report  for  1873  are  here 
introduced: 

In  the  early  spring  of  1861  the  American  civil  war  was  inaugurated, 
and  the  United  States  was  hurriedly  converted  into  a  vast  military  encamp- 
meiit.  In  all  the  cities  that  had  been  favorite  haunts  of  cholera  in  former 
years,  from  the  Penobscot  to  the  Rio  Grande,  and  from  the  Missouri  to 
the  Atlantic  ocean,  troops  were  collected,  and  vast  armies  were  concen- 
trated in  the  worst  malarial  regions  of  the  L^nited  States,  the  valleys  of 
the  Potomac,  Ohio  and  Mississippi  rivers. 

It  is  estimated  that  during  the  years  of  this  war  the  United  States 
army  had  in  the  field  an  aggregate  of  3,335,942  men,  or  that  the  mean 
strength  of  the  armies  was  about  783,906  men.  These  troops  were  in 
camp,  constantly  exjDOsed  to  all  the  vicissitudes  of  the  campaigns,  or  were 
in  hospitals  where,  in  spite  of  the  lavish  precautions  which  were  adopted, 
ot  infrequently  all  the  disadvantages  of  overcrowding  and  deficient  food 
were  present.  Vast  numbers  of  men  were  transported  to  and  from  the 
scene  of  active  operations  upon  steam  transports.  A  very  small  percentage 
of  the  troops  were  in  permanent  fortifications.  Vast  prison  pens  were 
formed,  in  which  overcrowding,  bad  ventilation,  indifferent  police,  and 
unsuitable  food  were  present  to  cooperate  with  local  malarial  influences 
upon  the  unfortunate  prisoners. 

The  record  of  the  medical  history  of  the  war  demonstrates  that  there 


THE  EPIDEMIC  OF   1866.  99 

occurred  in  the  army  of  the  United  States,  of  diseases  of  malarial  origin, 
1.-1:68,410  cases,  with  46,310  deaths;  of  intestinal  diseases,  1,765,501 
cases,  with  44,863  deaths.  Among  the  first  are  included  typhoid,  typhus, 
common  continued,  typho-malarial,  yellow,  remittent,  the  intermittents, 
and  congestive  intermittent  fevers.  Among  the  second  are  included 
diarrhoias,  dysenteries  and  cholera  morbus.  Of  the  latter,  during  the 
entire  war,  there  were  reported  but  three  hundred  and  five  deaths. 

It  must  be  borne  in  mind  that  these  figures  represent  but  one  arm 
of  the  United  States  service.  When  to  these  already  large  figures  the 
statistics  of  the  United  States  navy  are  added,  and  to  this  combination 
are  added  the  statistics  of  the  Confederate  armies,  the  mass  of  circumstantial 
evidence  is  overwhelming. 

In  the  very  region  where  it  is  claimed  that  every  epidemic  of  Asiatic 
cholera  that  has  visited  the  United  States  from  1832  to  1873  originated, 
de  710  vo  these  immense  bodies  of  men  were  congregated,  and  the  exceed- 
ing mortalities  occurred;  yet,  during  all  those  years  of  bloodshed  and  suf- 
fering, 7iot  one  case  of  epidemic  cholera  occurred.  Why?  Because  there 
was  none  of  the  specific  poison  of  cholera,  which  is  alone  cholera,  from  which 
the  disease  might  be  reproduced. 

It  was  my  fortune,  during  the  epidemic  of  1866,  to  witness  a  demon- 
stration of  the  efficacy  of  stringent  hygienic  precautions,  in  protecting 
small  communities  from  the  inroads  of  cholera,  as  well  as  the  portability, 
of  the  disease  by  means  of  cholera-infected  clothing. 

]Juring  the  war,  the  Pea- Patch  Island,  at  the  head  of  Delaware  Bay, 
upon  which  is  located  Fort  Delaware,  had  been  used  as  a  prison  for  Con- 
federate soldiers,  of  whom  many  thousands  during  the  war  had  been  con- 
fined at  that  point.  All  the  available  space  outside  the  fortification  had 
been  covered  by  the  buildings  occupied  as  prisons  and  hos23itals;  and  from 
necessity,  after  the  large  rate  of  occupancy,  the  island  at  the  close  of  the 
war  was  in  a  most  unsatisfactory  sanitary  condition.  During  the  fall  of  1865 
and  the  winter  of  1865-66,  all  unnecessary  buildings  were  removed  from 
the  island,  the  ditches  which  traversed  the  island  (the  surface  of  which 
was  below  high-water  mark)  were  drained  and  dredged.  Debris  of  all 
kinds  was  collected  and  burned,  and  the  island,  at  a  very  considerable 
l^ecuniary  outlay  on  the  part  of  the  general  government,  Avas  placed  in  a 
most  perfect  sanitary  condition.  In  the  latter  part  of  August,  1866,  a 
case  of  cholera  occurred  at  Delaware  Cit}^,  the  eastern  terminus  of  the 
Delaware  and  Chesapeake  canal,  distant  from  Fort  Delaware  one  and  a 
quarter  miles,  from  which  town  the  garrison  obtained  its  mail  and  sup- 
plies of  all  characters.  The  first  case  occurred  in  the  jierson  of  a  canal 
boatman,  and  spread  to  the  inhabitants  of  the  town,  and  a  mild  epidemic 
Avas  instituted.  Shortly  afterAvard  the  toAvn  of  New  Castle,  Del.,  Salem 
and  Bridgeton,  N.  J.,  Avere  infected  Avith  the  disease,  thus  compl^etely  en- 
circling the  post  Avithin  lines  of  cholera  infection.  By  my  adA-ice  the 
commanding  officer  at  the  post  instituted  a  rigid  system  of  isolation.  But 
one  boat,  with  a  picked  crew,  was  alloAved  to  leave  the  island  each  day; 
and  of  this  crew  but  one  man,  the  coxsAA'ain,  a  most  reliable  and  intelli- 
gent man,  Avas  permitted  to  enter  the  toAvn.  By  this  man  the  mail  and  all 
necessary  supplies  Avere  obtained,  and  by  this  boat  were  couA^eyed  to  the 
island.  The  commissary  department  having  been  most  liberally  supplied, 
no  stores  in  large  bulk  were  required  to  be  transported  to  the  island. 
Although  the  epidemic  during  the  season  Avas  so  often  carried  into  the 
toAvns  that  have  been  named,  in  the  vicinity  of  Fort  DelaAvare,  as  to  in- 


100  ASIATIC  CHOLERA. 

stitute  two  distinct  epidemics,  no  case  of  cholera,  or  of  any  disease  assimi- 
lating it,  occurred  upon  the  island,  beyond  the  ordinary  diarrhoea  of  the 
season,  with  but  a  single  exception,  which  can  be  most  satisfactorily  ac- 
counted for.  The  isolation  of  the  post  which  had  been  instituted  had 
been  most  rigidly  maintained,  and,  with  the  exception  of  the  coxswain 
of  the  boat's  crew  already  mentioned,  no  person  but  the  post  surgeon  had 
been  allowed  to  leave  the  island.  As  post  siirgeon,  my  services  had  fre- 
quently been  asked  during  the  prevalence  of  the  epidemic;  and  the  precau- 
tion always  had  been  adopted  of  changing  my  clothing  in  an  isolated  shed 
upon  one  of  the  wharves  every  time  I  left  and  returned  to  the  island.  Con- 
vinced of  the  non-infectiousness  of  the  disease  by  some  instances  Avhich 
seemed  to  me  to  be  inexplicable,  one  evening,  on  returning  to  the  island 
weary  and  exhausted  by  a  fatiguing  day's  work,  I  went,  in  the  clothes  in 
which  I  had  been  working  over  a  cholera  patient  in  Delaware  City,  to 
my  quarters,  undressed,  and  retired  in  the  same  room  with  my  wife,  at 
that  time  in  extremely  delicate  health,  and  the  clothing  remained  in  her 
room  throughout  the  night.  The  next  day  my  wife  had  a  diarrhoea  which 
she  alloAved  to  continue  for  two  days  without  calling  my  attention  to  it; 
upon  the  third  day  cholera  was  suddenly  developed  at  an  early  hour  in  the 
morning;  she  became  fully  collapsed,  and  reacted  only  after  the  most 
severe  struggle.  Disinfectants  were  freely  used,  every  means  of  isolation 
was  employed,  and  no  other  cases  occurred. 


THE  EPIDE^nC  OF  1867.  j^Ql 


CHAPTEE   XV. 

THE  EPn)E]\nC   OF   1867  IN  THE  UNITED   STATES  AEMY. 

From  all  obtainable  evidence  it  seems  that  there  -svasa  '"  holding  over" 
of  the  cholera  germs  from  the  subsidence  of  the  epidemic  of  1866,  as  had 
been  the  case  in  previous  epidemics,  to  re-develop  with  increased  virulence 
as  the  warm  rays  of  the  sun  reached  their  "  nidus  "  in  1867. 

This  was  notably  the  fact  as  regards  the  cities  of  New  Orleans,  La. ,  and 
St.  Louis,  Mo.,  and  at  the  military  station  of . J  elf  erson  Barracks,  Mo.  At 
Xew  Orleans  the  epidemic  of  1866  continued  until  late  in  the  month  of  De- 
cember; perhaps  it  had  not  died  out  in  the  early  days  of  January,  186?. 
It,  however,  reappeared  in  the  month  of  June,  1867. 

At  St.  Louis,  Mo.,  the  epidemic  of  1866,  lasted  through  the  moiith 
of  Xovember,  perhaps  into  December,  and  re-developed  almost  simulta- 
neously Avith  the  Xew  Orleans  outbreak,  in  the  month  of  June,  1867. 

At  Fort  Gibson.  Ark.,  the  epidemic  lasted  into  Xovember,  1866,  and 
re-appeared  among  the  Indians  and  negroes  who  lived  in  the  vicinity  of 
that  post  during  the  last  days  of  June,  1867. 

At  Jelferson  Barracks,  Mo.,  where  in  the  post  and  the  camp  of  the 
56tli  U.  S.  Colored  Troops  a  virulent  epidemic  of  cholera,  accompanied 
by  a  large  number  of  cases  of  simple  diarrhoea  in  August  and  September 
1866,  and  where  many  cases  of  acute  diarrhoea  occurred  during  the  remain- 
ing months  of  that  year,  a  few  cases  of  cholera  occurred  in  July,  1867; 
but  while  Jefferson  Barracks  in  1867  did  not  suffer  from  an  extended  epi- 
demic, it  is  an  assured  fact  that  a  regiment  of  U.  S.  troops  from  that  post 
— at  which  they  had  been  organized  and  from  which  they  Avere  equipped 
for  service — occasioned  a  most  disastrous  outbreak  of  cholera  on  the  high, 
dry  plains  of  Avestern  Kansas,  and  it  is  to  this  diffusion  of  the  epidemic  of 
1867  that  especial  attention  Avill  be  directed. 

In  vieAv  of  the  possible  re-development  of  epidemic  cholera,  a  system 
of  stringent  hygienic  measures  had  been  adopted  at  all  military  posts. 
That  these  measures  Avere  to  a  gi-eat  extent  effectual  is  evident  from  a 
study  of  the  Eeport  on  Epidemic  Cholera  and  Yellow  Fever  during  the 
year  1867,  by  the  late  Surgeon  J.  J.  Woodward,  U.  S.  Army,  from  Avhicli 
report  the  folloAving  is  taken:  "At  the  majority  of  the  points  affected  it 
(cholera)  occurred  first  among  the  citizens  and  afterAA-ard  appeared  among 
the  troops,  but  it  Avas  not  ahvays  possilile  to  obtain  the  date  of  the  first 
case  among  the  citizens,  and  hence  it  is  not  possible  to  assert  that  this  AA'as 
the  invariable  rule,  though  it  is  believed  it  Avas  so."  This  remark  cannot, 
howcA'er,  apply  to  the  Kansas  diffusion  of  1867,  for  in  that  year  and  in 
that  locality  all  the  facts  point  to  the  agency  of  troops,  although  the  actual 
transportation  of  recognizable  cholera  Avas  not  at  the  time  knoAvn  to  liaA'e 


][09  ASIATIC  CHOLERA. 

taken  place.  The  38tli  U.  S.  Infantry  (colored)  was  organized  at  Jeiferson 
Barracks,  Mo.,  early  in  the  year  1867.  Kecruiting  rendezvous  for  this 
regiment  had  been  established  in  all  the  large  cities,  notabl}^  Chicago,  111. ; 
Cincinnati,  Ohio;  Philadelphia,  Pa.;  Baltimore,  Md. ;  Louisville,  Ky. ; 
Nashville  and  Memphis,  Tenn. ;  Vicksburg  and  Jackson,  Miss. ;  Atlanta 
and  Augusta,  Ga. ;  New  Orleans,  La. ,  and  St.  Louis,  Mo.  From  these 
rendezvous  an  aggregate  of  over  twelve  hundred  (1,200)  recruits,  mostly 
discharged  soldiers  from  volunteer  regiments,  had  been  massed  at  regi- 
mental headquarters  at  Jeiferson  Barracks. 

At  Jefferson  Barracks,  during  the  time  of  occupancy  by  these  troops,  no 
case  of  cholera  occurred,  nor  did  a  case  develop  until  twenty -four  (24)  days 
after  the  last  detachment  of  the  38th  Infantry  had  left  that  post,  but  it 
is  stated  by  Woodward  that  prior  to  this  final  movement  of  the  regiment 
"  a  considerable  number  of  cases  of  diarrhoea  occurred  "  among  the  men. 
This  regiment  being  destined  for  duty  in  the  District  of  New  Mexico,  and 
the  Indians  on  the  Kansas  jDrairies  having  opened  hostilities  by  attacking 
parties  of  workmen  along  the  line  of  the  Kansas  Pacific  Railwa3%  com- 
panies were  sent  forward  to  the  line  of  that  road,  after  having  received 
their  clothing  and  camp  and  garrison  equipage  from  the  storehouses  at 
Jefferson  Barracks.  On  March  20th  Companies  A  and  B,  were  sent 
forward  and  arrived  at  Fort  Riley,  Kansas,  on  the  24th.  and  remained  at 
that  post  until  May  13th,  when  they  were  ordered  to  Fort  Ilarker,  Kansas, 
arriving  at  that  post  on  the  15tli  same  month.  Companies  C,  E, 
I,  and  G,  left  Jefferson  Barracks  on  the  12th  of  May,  arrived  at  Fort 
Harker  on  the  17th,  where  Company  G  took  station  (until  June  Stli, 
Avhen  it  was  marched  to  Fort  Hayes,  arriving  June  lo),  while  the  other 
Companies  (C,  E,  and  I,)  marched  for  Fort  Hayes,  Kansas,  where 
they  arrived  May  28th.  Company  K  left  Jefferson  Barracks  on  the 
9th  of  June,  and  arrived  at  Fort  Riley  on  June  12th;  left  Fort  Riley 
June  19th,  and  arrived  at  Fort  Harker  June  22d.  Companies  D  and  F 
left  Jefferson  Barracks  June  19th  and  arrived  at  Fort  Harker  June  25th. 
The  regimental  headquarters  left  Jefferson  Barracks  June  22d  and 
arrived  at  Fort  Harker  June  27th.  Each  of  these  movements  was  made 
through  St.  Louis — by  rail  to  Kansas  City,  Mo.,  thence  by  rail  as  far  as 
the  railway  construction  was  completed,  and  by  march  from  the  termination 
of  the  track  to  the  military  stations  named. 

The  first  reported  cholera  case  in  Kansas  during  the  epidemic  of  1867 
occurred  in  the  person  of  a  quartermaster's  employee  at  Fort  Riley,  on  the 
22nd  of  June.  Companies  A  and  B  of  the  38th  Infantry  had  been 
on  duty  at  Fort  Riley  for  fifty  days  (50),  and  Company  K  of  the  same 
regiment  had  been  for  ten  days  (10)  at  the  post,  leaving  there  on  June 
19th,  three  (3)  days  before  the  occurrence  of  the  first  cholera  case.  All 
these  troops  Avere"  suffering  much  from  diarrhoea,  and  companies  D  and 
I,  in  passing  Fort  Riley,  en  route  for  Harker,  had  left  a  number  of 
men  sick  with  diarrhoea.  "^(Woodward).  The  case  of  June  22d  proved  fatal 
in  a  few  hours.  Being  casually  at  Fort  Riley,  I  had  an  opportunity  of 
inspecting  this  case.  All  the  characteristic  symptoms  of  malignant  cholera 
Avere  present,  but  owing  to  the  energetic  precautions  of  Surgeon  B.  J.  D. 
Irwin,  L^.  S.  A. ,  the  disease  did  not  become  epidemic. 

On  the  27th  of  June,  the  headquarters  38th  Infantry  with  Companies 
A,  B,  D,  F,  H  and  K  were  on  duty  at  Fort  Harker,  Kansas,  Companies 
A,  B  and  K  being  on  duty  in  garrison.  The  headquarters  and  Companies 
D.  H  and  F  were  in  camp  a  short  distance  southwest  of  the  post.  To  the 
command  in  camp  I  was  attached  as  medical  officer. 


THE  EPIDEMIC  OF   1867.  103 

On  the  281  h  of  June  companies  D  and  F  (from  the  camp)  left 
Fort  Harker  on  the  march  for  New  Mexico,  accompanied  by  Assistant 
Surgeon  George  McGill,  U.  S.A. 

Owing  to  an  interruption  caused  by  washouts  on  the  railroad,  the  full 
complement  of  medical  and  hospital  supplies  for  this  regiment  had  not  been 
received  at  the  date  of  departure  of  that  detachment,  and  Doctor  McGill 
had  been  supplied  with  all  that  had  been  provided  for  the  camp  of  the  reg- 
imental headquarters  and  the  companies  which  should  accompany  it. 
I  had  ridden  with  the  lamented  McGill  to  the  crossing  of  the  Smoky 
Hill  river,  a  few  miles  distant  from  camp,  and  on  returning  was  asked  by 
Acting  Asst.  Surgeon  Ira  Perry,  U.  S.  A.,  to  see  with  him  a  citizen  em- 
ployed by  the  beef  contractor  at  Fort  Harker.  This  man  was  in  a  "  dug- 
out" close  to  a  filthy  slaughter  pen  about  a  mile  south  of  the  camp.  It 
was  a  case  of  cholera,  and  the  man  died  within  a  few  hours.  This  case  was 
the  first  indication  of  cholera  being  near  the  command.  The  same  even- 
ing a  man  of  Company  H  in  the  camp  of  the  3Stli  Infantry  was  taken 
with  cholera,  and  for  lack  of  any  means  with  which  to  treat  him  in  camp 
he  was  sent  to  hospital  at  Fort  JHarker,  where  he  died  the  next  day.  On 
the  "2 9th  a  second  case  occurred,  who  was  also  sent  to  hospital  at  Fort 
Harker,  where  he  recovered.  On  the  30th  a  third  case  was  also  sent  to 
hospital  in  Fort  Harker,  where  lie  died  in  a  few  hours.  On  July  1st  five 
cholera  cases  occurred.  The  medical  and  hospital  supplies  for  the  38th 
Infantry  having  arrived,  these  men  were  treated  in  camp  hospital.  On 
the  2d  three  (3)  cases  occurred  in  camp;  on  the  3d  four  (4)  cases;  on  the 
4th  two  (2)  cases;  on  the  fifth  one  (1)  case,  and  on  the  7th  one  (1)  case. 
These  cases  were  accompanied  by  fourteen  (14)  cases  of  painless  diarrhcea. 
Of  these  cholera  cases  five  (5)  were  fatal.  From  July  7th  no  new  cases  of 
cholera  occurred  in  Company  H.  In  the  camp  of  the  38th  Infantry, 
the  most  rigid  precautionary  measures  were  at  once  adopted,  and  as  far  as 
was  possible  the  men  were  debarred  from  communication  with  the  post. 
The  water  supply  was  brought  from  an  isolated  spring  two  miles  distant 
from  camp,  and  the  privy  sinks  were  carefully  disinfected.  All  infected 
articles  of  clothing  and  bedding  were  destroyed  by  fire. 

The  first  cholera  case  in  Fort  Harker  occurred  on  June  29th,  in  the 
person  of  the  child  of  a  quartermaster's  employee.  This  case  occurred 
fifteen  hours  (15)  after  the  first  cases  sent  from  Company  H  had  been  re- 
ceived in  the  post  hospital.  The  same  day  the  mother  was  taken  with 
cholera  (the  child  at  10  a.m.,  the  mother  at  12  m.),  and  the  father  was 
taken  with  the  disease  the  next  day.  The  cases  of  mother  and  child  were 
fatal.  The  same  day  (June  29)  a  soldier  from  Company  B,  38th  Infantry 
(one  of  the  companies  serving  in  garrison)  was  admitted  to  post  hospital 
with  cholera  at  6  o'clock  p.  m.  '  From  these  cases  an  epidemic  originated 
which  was  wide-spread  in  the  mortality  and  mental  anguish  which  it  occa- 
sioned. It  will  be  seen  that  the  epidemic  was  preceded  by  four  distinct 
explosions  of  cholera,  in  individuals  whose  cases  were  not  dependent  upon 
each  other.  The  emplo3'ee  of  the  beef  contractor,  distant  fully  a  mile  and 
a  half  from  the  camp  of  the  38th  Infantry;  the  soldier  of  H  company  in 
the  camp  about  one-third  of  a  mile  from  Fort  Harker  (June  2Sth);  the 
family  of  a  quartermaster's  employee  who  lived  over  half  a  mile  from  the 
preceding  cases;  and  in  the  soldier  in  B  companv,  then  in  garrison  at 
Fort  Harker  (June  29th). 

'  Report  of  Surgeon  Geo.  M.  Sternberg,  U.  S.  A. 


104 


ASIATIC  CHOLERA. 


This  instance  of  cliolera  outbreak  has  always  been  a  peculiarly  inter- 
esting study  to  me.  After  eigliteen  years,  the  scenes  of  anguish  and  of 
heroic  devotion  to  duty  that  I  witnessed  are  as  fresh  to  my  mind  as  they 
were  then.  The  solution  to  the  problem  of  its  introduction  is,  to  my 
mind,  to  l^e  found  in  the  fact  that  the  companies  of  the  38th  regiment 
received  their  clothing  and  camp  equipage  at  Jelferson  Barracks;  that  such 
articles  were  infected  with  the  cholera  germ,  and  that  when  they  were  taken 
into  constant  use,  from  contact  with  them  the  disease  was  developed  in 
the  regiment.  That  from  the  same  contact  the  acute  diarrhoea  which  is 
reported  to  have  been  so  prevalent  among  these  troops  Avas  occasioned,  and 
that  owing  to  the  hygienic  precautions  adopted  the  cholera  germ  contained 
in  the  diarrhoeal  dejecta  did  not  obtain  any  suitable  "  hot-bed"  in  which 
the  process  of  prolification  could  be  accomplished  until  Fort  Harker  was 
reached,  where,  the  post  being  in  process  of  construction,  all  sanitary 
precautions  had  not  iDcen  observed;  for  it  was  reported  that  "the  police 
of  the  camps  was  not  good  when  cholera  first  made  its  appearance.  Some 
of  the  company  sinks  were  in  wretched  condition,  and  there  were  several 
offensive  holes  about  the  post  where  slops  and  garbage  from  the  kitchen 
had  been  thrown. "  '  The  water  in  use  was  obtained  from  a  spring  in  the 
bank  of  a  creek  a  quarter  of  a  mile  west  of  the  post,  and  was  stored  in 
barrels  for  use. 

Companies  A  and  B  had  been  on  duty  at  Fort  Harker  for  forty-three  ^ 
(43)  days  before  the  epidemic  outbreak.  They  were  in  tents  and  were 
using  camp  furniture  belonging  to  the  post.  ComjDany  K  had  been  in 
camp  six  (6)  days.  Companies  D  and  F  had  been  in  camp  three  (3) 
days,  and  the  headquarters,  with  Company  H,  had  been  in  camp  two  (2) 
days  before  the  disease  occurred.  The  regimental  headquarters  and  com- 
panies K,  D,  F  and  H  were  in  tents  and  using  camp  furniture  brought  from 
Jefferson  Barracks. 

There  was  a  constant  communication  between  the  officers  and  men  of 
the  newly  arrived  troops  and  those  who  had  served  some  time  at  the  post. 
The  newly  ai'rived  men  could  have,  without  infringement  of  duty,  eaten 
with,  drank  from  the  same  water,  and  used  the  same  privies  as  were  provided 
for  their  comrades.  Tli*s  access  on  the  part  of  the  men  of  the  38th  Infant- 
ry, could  readily  have  been  extended  to  one  company  of  the  STth  U.  S. 
Infantry  (white),  occupying  a  building  within  the  post  limits,  a  company 
of  the  iOth  U.  S.  Cavalry  (colored),  in  camp  near  post,  the  camp  of  quar- 
termasters' employees,  several  hundred  in  number,  who  were  at  work  in 
the  construction  of  Fort  Harker,  and  the  camp  of  four  (4)  companies  of 
Kansas  militia  who  had  been  mustered  into  the  U.  S.  service.  All  the  cir- 
cumstances were  favorable  for  a  virulent  development  of  cholera,  and  the 
results  of  the  epidemic  fearfull}^  demonstrated  their  presence. 

As  has  already  been  stated,  a  detachment  of  the  38th  U.  S.  Infantry 
marched  from  Fort  Harker  on  the  morning  of  June  28th.  This  detach- 
ment consisted  of  Companies  D  and  F,  who  had  left  Jefferson  Barracks, 
Mo.,  June  19th,  arrived  at  Fort  Harker  June  25th,  and  Avho  had  left 
several  diarrhoeal  cases  at  Fort  Riley  as  they  passed  that  post.  At  the  close 
of  the  first  day's  march  of  this  detachment  a  case  of  cholera  .occurred,  and 
on  each  succeeding  day  until  July  10th  one  or  more  cases  occurred,  giving 
a  total  of  thirty-one  (31)  cases  with  twelve  (12)  deaths,  the  last  case  being 
on  July  26th.     The  mean  strength  of  this  command  Avas  232  men. 

'  Report  of  Surgeon  Geo.  M.  Sternberg,  U.  S.  A. 


THE   EPIDEMIC   OF    1867.  1()5 

By  this  detachment  cholera  was  communicated  to  the  troops  serving  at 
Fort  Zara  (June  39),  Fort  Larned  (July  3),  and  Fort  Dodge  (July  7).  By 
death  from  cholera,  the  medical  corps  of  the  army,  suffered  the  great  loss 
of  Assistant  Surgeon  George  M.  McGill,  Brevet  Lieutenant-Colonel  U.  S. 
army,  a  most  accomplishecl,  devoted,  self-sacrificing  officer.  On  the  16th 
of  July  when  a  few  miles  west  of  Pretty  encampment,  a  fortified  stage- 
station  on  the  overland  mail-route,  3[rs.  McGill  was  taken  sick  with 
cholera.  Finding  it  impossible  to  render  his  wife  suitable  assistance  while 
the  column  was  moving,  Doctor  McGill  moved  his  ambulance  off  the 
road,  established  a  solitary  camp,  and  devotedly  cared  for  her  until  the 
anguish  was  over;  then,  witli  his  own  hands,  preparing  her  body  for  the 
grave,  omitting  no  precautions  which  might  preserve  it  from  external  in- 
jury, or  which  might  in  case  of  disinterment  prevent  the  communication 
of  the  disease  to  others,  he  returned  to  Pretty  encampment,  where  in  per- 
son he  superintended  all  the  details  of  burial.  Then  mounting  his  horse, 
he  endeavored  to  overtake  the  command;  after  riding  some  eighteen  miles 
he  was  obliged  to  dismount  by  the  roadside  a  victim  to  the  disease,  and  in 
a  few  hours  his  earthly  work  was  over.  A  purer,  nobler  heart  is  never  to 
be  found. 

On  the  10th  of  July,  the  headquarters  of  the  38tli  Infantry  with 
Companies  A  and  K  took  the  road  for  New  Mexico.  Company  H, 
which  had  been  treated  in  camp,  and  in  which  cholera  seemed  to 
have  been  stamped  out,  was  marched  into  Fort  Harker,  and  two 
companies  from  the  cholera-infected  post  where  they  had  been  con- 
sta]itly  exposed  to  the  epidemic  influence,  although  both  had  been  com- 
paratively free  from  the  disease,  formed  the  column.  Before  leaving 
Fort  Harker  a  rigid  inspection  of  these  companies  was  made.  All  suspi- 
cious cases  were  left,  so  that  the  command  started  with  an  absolutely  clean 
sick  report,  and  a  most  ample  supply  of  all  medical  and  hospital  property. 
The  command  numbered  two  hundred  and  twenty  (330)  enlisted  men, 
twelve  officers  (13)  thirty-seven  (3?)  ladies,  children,  and  servants,  forty- 
four  (44)  quartermaster's  employees,  and  a  family  of  ten  (10)  citizens— a 
total,  of  three  hundred  and  twenty-four  (334)  persons.  On  each  day's 
march  great  care  was  taken  to  avoid  all  old  camp-grounds.  The  first  day 
passed  without  any  sickness.  On  the  second  day  a  case  of  cholera  occurred 
in  a  man  of  A  company  who  had  acted  as  nurse  in  the  cholera  hospital  at 
Fort  Harker,  and  when  camp  was  made  on  that  day  (July  31),  five  (5)  well 
marked  cases  of  cholera  and  four  (4)  of  painless  diarrhoea  were  reported. 
These  cases  were  isolated  as  far  as  was  jjracticable  and  a  strict  surveillance 
over  the  command  was  instituted.  None  of  these  cases  proved  immedi- 
.ately  fatal.  July  33,  the  command  moved  to  Walnut  creek  and  camped 
on  the  east  bank,  for  the  reason  that  the  entire  line  of  the  western  bank 
for  several  miles  was  a  defiled  camp-ground,  having  been  on  constant  occu- 
pancy by  freight  trains  passing  to  and  from  New  Mexico.  During  this 
day  two  cholera  cases  occurred,  neither  immediately  fatal.  July  33d  the 
command  was  detained  in  camp,  the  stream  becoming  rapidly  flooded  (as 
occasionally  occurs  to  prairie  streams,  without  warning).  Two  new  cases 
occurred,  and  two  of  the  cases  attacked  on  the  31st,  died.  The  symptoms 
of  all  other  cases  of  the  disease,  which  been  considered  as  passing  to  con- 
valescence, deepened  and  many  cases  of  diarrhoea  were  reported.  At  Fort 
Zara,  one  mile  distant,  a  re-development  of  the  disease  occurred  in  the  per- 
son of  the  officer  commanding,  who  died  after  a  few  hours'  illness.  No 
commvinication  occurred  between  the  commands,  except  in  the  person  of 


106 


ASIATIC  CHOLERA. 


the  medical  officer.  July  34tli  the  command  was  still  detained  in  camp. 
Eight  (8)  cases  of  cholera  and  five  (5)  of  diarrhoea  occurred.  Two  (2) 
cases  died,  one  a  man  taken  sick  on  the  22d,  the  other  a  case  of  the  24th. 
July  25th,  the  command  crossed  Walnut  creek  and  marched  to  tlie  bank 
of  the  Arkansas  river,  leaving  the  ordinary  line  of  travel  several  miles  to 
the  north,  taking  a  road  Avhich,  on  account  of  Indian  hostilities,  had  not 
been  vised  for  nearly  a  year,  and  on  which  no  trails  or  signs  of  camps  were 
found.  On  leaving  the  camp  on  AYalnut  creek  a  very  malignant  case  oc- 
curred in  a  man  of  "Company  A,  who  although  he  had  not  been  reported 
sick,  but  marched  out  of  camp  in  the  ranks,  was  dead  four  hours  later. 
The  same  day  one  case  of  those  attacked  the  previous  day  died,  and  five 
(5)  new  cholera  cases  with  fourteen  (14)  cases  of  diarrhoea  occurred.  The 
epidemic  influence  continued  until  the  30th  of  the  month,  Avhen  it  subsided 
with  the  exception  of  an  isolated  non-fatal  case  which  occurred  August 
10th. 

It  can  be  confidently  asserted  that  this  command  was  in  no  way  re- 
sponsible for  any  cholera'diifusion  after  the  line  of  march  from  Fort  Harker 
was  taken  up.  "  The  moving  hospital  consisted  of  a  fully  equipped  Auten- 
rieth  medical  wagon,  a  very  abundant  supply  of  disinfectants,  stimulants 
and  hospital  stores,  a  full  supply  of  hospital  tents,  three  ambulances  and 
several  army  wagons.  A  close  watch  was  kept  over  all  individuals  in  the 
command.  "  Every  case  of  diarrhoea  was  promptly  discovered  and  actively 
treated.  No  man  suffering  from  diarrhoea  in  any  form  was  permitted  to 
continue  in  ranks,  but  was  placed  at  once  in  an  ambulance  or  wagon.  On 
some  days'  march  nearly  the  entire  command  was  thus  transported.  A 
sanitary  detail  marching  in  rear  of  column  prevented  straggling.  Any  one 
compelled  by  necessity  to  fall  out  of  line  was  taken  under  observation  and 
his  excreta  was  inspected  by  an  intelligent  assistant,  who  saw  that  the  ^de- 
jecta were  properly  disinfected  and  covered  with  fresh  earth  before  it  was 
abandoned.  The  march  of  each  day  was  over  before  the  heat  became 
great;  frequent  halts  for  rest  were  made.  Drinking  water  was  taken  from 
the  Arkansas  river — at  that  point  a  clear,  swift-flowing  stream.  I  find  it 
recorded  in  my  note-book  of  this  time:  "  The  effect  of  remaining  in  camp 
was  evidently  so  pernicious  to  the  morale  of  the  command  that  it  was  de- 
cided to  move  camp  each  day,  if  enabled  to  make  only  a  few  miles.  It  is 
a  noticeable  fact  that  while  daily  marches  were  made,  even  in  the  unvary- 
ing scenery  of  the  Arkansas  valley,  the  morale  of  the  entire  command  was 
unaffected;  but,  on  the  other  hand,  one  day  of  rest,  or  even  the  prospect 
of  remaining  twenty-four  hours  in  camp  developed  cases  of  choleraphobia." 

The  hospital  camp  was  each  day  pitched  to  the  leeward  and  at  a  suffi- 
cient distance  from  the  camp  of  the  troops.  In  this  camp  narrow  pits 
were  dug  to  receive  the  excreta  and  the  water  used  in  cleaning,  ever}i;hing 
before  being  emptied  into  these  pits  was  thoroughly  disinfected  with  car- 
bolic acid,  and  after  each  use  covered  with  fresh  earth.  All  soiled  articles 
of  clothing  or  bedding  were  destroyed  by  fire.  Before  leaving  a  camp  each 
pit  was  again  disinfected  by  strong  acid  solutions  and  filled  to  the  surface 
with  fresh  earth.  The  ambulances  and  wagons  used  in  transporting  the 
sick  were  daily  cleaned  and  disinfected.  Similar  precautions  were  adopted 
in  the  main  camp,  where  the  men  were  kept  under  constant  and  close 
supervision  by  the  company  officers. 

No  communication  was  permitted  between  this  command  and  any  posts 
or  stations  along  the  line  of  march,  save  in  the  persons  of  the  medical 
officer  and  quartermaster.     In  each  instance  the  line  of  march  diverged 


THE  EPIDEMIC  OF   1867.     ''"^''-'^y  01^ 


107 


SO  as  to  leave  the  post  at  least  two  (2)  mile.s  distant,  and  in  no  instance 
was  a  camp  made  nearer  any  post  in  a  less  distance  than  three  (.3)  miles. 
After  crossing  the  Arkansas  river  and  reaching  the  territory  of  New  Mexico 
a  quarantine  camp  was  made  for  two  weeks  before  marching  into  Fort 
Union  on  August  31st. 

Among  the  enlisted  men  of  this  command,  forty-six  (40)  cholera  cases 
with  seventeen  (17)  deaths  occurred.  One  (1)  fatal  case  occurred  amono- 
the  quartermaster's  teamsters.  Three  (3)  cases  with  two  (2)  deaths  oc- 
curred in  the  family  of  citizens,  and  one  (1)  non-fatal  case  occurred  in  an 
officer's  family,  making  a  total  of  fifty-one  (51)  cases  with  twenty  (20) 
deaths. 

No  cases  of  cholera  occurred  among  the  hospital  attendants  or  drivers 
of  hospital  wagons  or  ambulances.  The  last  cholera  death  among  the 
citizens  accompanying  the  command  was  on  July  30th.  The  last  cholera 
death  among  the  troops  of  this  command  occurred  on  July  29th.  The 
latest  developed  case  among  the  troops  was  on  July  2Sth.  The  last  case 
in  the  entire  command  was  an  isolated  non-fatal  case  August  lOtli. 

The  movements  of  Companies  D  and  F  and  of  Companies  A  and  K  have 
thus  been  accounted  for.  It  has  been  shown  that  these  comi)anies  left 
Fort  Harker  at  dates  nearly  a  month  apart,  and  that  it  Avas  by  the  first  of 
these  detachments  that  epidemic  cholera  was  distributed  to  military  sta- 
tions on  the  line  of  march.  It  is  interesting  to  observe  the  effect  of  the 
movements  of  the  other  companies  of  this  regiment.  Companies  B  and 
H  remained  at  Fort  Harker  until  after  the  subsidence  of  the  epidemic. 
It  Avill  be  remembered  that  H  company  had  been  moved  from  camp,  in 
which  it  had  undergone  a  thorough  system  of  disinfection,  to  the  garrison 
of  Fort  Harker  vdien  the  regimental  headquarters  moved  from  that  post. 
I  was  afterward  informed  by  the  captain  of  the  company  that  no  cases  of 
cholera  occurred  among  his  men  after  the  7tli  of  July.  The  remainino- 
four  companies  of  this  regiment  C,  E,  Gr,  and  I,  were  on  duty  from  the  25th 
of  May  at  Fort  Hayes,  Kansas,  where  on  July  11th  cholera  occurred 
among  them.  This  outbreak  was,  however,  preceded  by  the  death  of  a 
citizen  who  had  just  arrived  from  Salina,  whither  the  cholera  had  been 
carried  from  Fort  Harker.  During  July  and  August  the  disease  was 
confined  to  the  colored  troops,  but  on  the  1st  of  September  the  white 
troops  were  infected.  From  Fort  Hayes  and  Fort  Harker  cholera  was 
carried  by  the  movements  of  troops  to  Downer's  Station,  Grinnell 
Springs,   Monument  Station,  and  Fort  Wallace ;  and  by  the  movements 


were  cholera-infected. 

The  special  epidemic  which  followed  the  arrival  of  the  companies  of 
the  3Sth  U.  S.  Infantry  at  Fort  Harker,  lasted  during  the  months  of  July, 
August,  September  and  the  early  days  of  October,  and  was  distributed 
over  the  entire  western  portion  of  the  State  of  Kansas. 

The  ej)idemic  of  cholera  which  broke  out  in  June,  1867,  among  the 
negroes  and  Indians  around  Fort  Gibson,  spread  to  Company  D,  lOth  U.  S. 
Cavalry,  and  was  by  them  in  July  carried  to  Fort  Arbuckle,  where  a  mild 
epidemic  occurred.  Early  in  the  month  of  July,  two  companies  of  the 
6th  U.  S.  Infantry,  en  route  from  Fort  Smith  to  Fort  Arbuckle,  passed 
over  the  road  and  perhaps  used  the  camp-grounds  that  had  been  used  bv 
D  troop,  10th  Cavalry  (the  existence  of  cholera  being  unknown  to  tnem\ 


108  .,,,    >;;J^If.T^^  CHOLERA. 

,,^^..,^ '^,(5  ^^^  ^'-  ;■.;,,(. 

July  I4th  a  severe  epid0n\fo  'cTccYiti-efl  among  tliem,  and  in  a  command  of 
oiue,  hundred  and  twenty-nine  {129)  officers  and  men,  forty  (40)  cholera 
cases  with  sixteen  (16)  deaths  occurred. 

On  the  31st  of  August,  1867,  a  fatal  case  of  cholera  occurred  on  Gov- 
ernor's Island,  New  York  harbor,  in  the  person  of  a  recruit  who  had  been 
received  the  evening  previous  from  St.  Louis,  Mo.  In  the  detachment 
to  Avhich  this  man  belonged  one  fatal  case  had  occurred  after  the  recruit 
had  left  St.  Louis,  and  the  man  attacked  after  reaching  Governor's  Island 
had  been  in  attendance  upon  him.  No  additional  cases  occurred  on  Gov- 
ernor's Island  until  August  31st,  when  ten  (10)  new  cases  occurred,  the 
first  four  (4)  being  in  persons  of  recruits  who  had  been  received  August 
28th  from  New  York  City,  Jersey  City  and  Philadelphia.  At  this  station 
during  the  months  of  August  and  September  thirty-five  (35)  cases  of 
cholera  with  eighteen  (18)  deaths  occurred. 

At  Fort  Wood,  Beclloe's  Island,  the  first  fatal  case  of  cholera  occurred 
August  25tli  in  the  person  of  a  St,  Louis  recruit,  who  had  been  in  contact 
with  the  cases  on  Governor's  Island.  During  August  and  September  ten 
(10)  cholera  cases  with  four  (4)  deaths  occurred.  In  the  movements  of 
recruits  from  these  depots  to  their  regiments  several  isolated  cases  occurred 
at  various  points,  but  no  diffusion  of  the  disease  occurred.  One  fatal  case 
was  reported  at  Plattsburg  Barracks,  N.  Y.,  in  person  of  a  man  who  had 
contracted  the  disease  on  Governor's  Island, 

On  the  23d  of  November  a  detachment  of  recruits  numbering  three 
hundred  and  ninety-eight  (398)  sailed  from  New  York  harbor  on  the 
steamer  Ealeigh,  en  route  for  Galveston,  Texas,  via  New  Orleans,  La.  On 
the  30th  of  November  a  second  detachment  numbering  five  hundred  and 
nine  (509)  recruits  sailed  from  New  York  harbor,  for  Austin  and  San  An- 
tonio, Texas,  via  New  Orleans, 

The  steamer  Raleigh  reached  New  Orleans  December  2d;  no  sickness 
on  board.  The  troops  destined  for  Texas  were  detained  on  board  on 
account  of  the  prevalence  of  cholera  in  the  city;  and  on  the  3d,  having 
been  transferred  to  the  steamer  W.  G,  Hewes,  sailed  for  Galveston.  De- 
cember 6th,  the  Hewes  arrived  at  Galveston  having  on  board  a  number  of 
cases  of  diarrhroa  having  rice-water  discharges,  one  case  progressing  to 
collapse,  but  none  had  died.  The  troops  were  disembarked  and  placed 
in  camp;  but  owing  to  bad  weather,  on  December  9th  they  were  trans- 
ferred to  the  barracks  of  the  17th  U.  S.  Infantry. 

On  December  11th  the  detachment  of  recruits  who  had  left  New  York 
harbor  November  30th,  arrived  at  Galveston,  after  having  been  detained 
one  day  at  New  Orleans,  (probably  Dec.  7th  or  8th),  In  this  detachment 
one  cholera  death  had  occurred  •  before  reaching  Galveston.  After  re- 
maining one  day  at  Galveston,  they  sailed  for  Indianola,  Texas,  leaving  a 
number  of  cholera-sick.  Among  these  men  thirteen  (13)  cases  with  two 
(2)  deaths  occurred  at  Indianola.  where  the  disease  did  not  spread  to  other 
troops.  At  Galveston,  cholera  was  carried  to  Hempstead,  Texas,  and  from 
Indianola  to  camp  near  Austin,  but  the  epidemic  was  of  a  mild  type. 

From  New  Orleans  the  epidemic  of  cholera  affected  slightly  the  garrison 
of  Jackson  Barracks;  it  was  carried  to  Fort  Jackson,  Miss,,  Vidalia,  La., 
Yicksburg,  Miss.,  Madison,  Ark,,  but  owing  to  the  stringent  hygienic 
measures  that  had  been  adopted  at  those  places  in  view  of  the  approach 
of  yellow  fever,  no  extended  epidemic  occurred. 


THE  EPIDEMIC  OF   1873.  |Q9 


CHAPTER  XVI. 

THE  EPIDEMIC  OF  1878  IN  THE  UNITED  STATES  AEMY. 

The  cholera  epidemic  of  1873  in  the  United  States  had  but  slight  effect 
upon  the  troops  serving  within  the  limits  of  the  epidemic  influence.  This 
epidemic  was  confined  to,  hut  prevailed  throughout,  the  valley  of  the  Mis- 
sissippi and  its  tributaries.  The  early  cases  occurred  in  the  city  of  New 
Orleans.  From  that  city  the  disease  was  carried  northward.  Again  were 
river  steamers  the  active  porters  in  the  epidemic  diffusion.  Cholera  be- 
came epidemic  at  all  points  attacked,  although  it  assumed  a  pandemic 
form  at  once.  During  the  entire  season  of  epidemic  influence  the  disease 
was  governed  by  the  same  well-defined  laws  that  had  been  presented  by  all 
other  demonstrations,  and  the  fact  that  the  disease  did  not  assume  its  ac- 
customed epidemic  violence  in  the  larger  cities,  and  that  its  most  malig- 
nant demonstrations  were  confined  to  small  country  towns  and  villages,  is 
alone  due  to  the  fact  that  the  larger  cities  were  jjrotected  by  energetic 
health  boards  assisted  by  the  active  coojoeration  of  municipal  authorities, 
while  in  the  small  country  towns  the  most  culpable  negligence  was  shown. 

At  many  of  the  cholera-infected  points.  United  States  troops  Avere 
stationed,  but  it  was  only  at  Monroe,  La.,  Nashville  and  Chattanooga, 
Tenn.,  Lancaster  and  Lebanon,  Ky.,  St.  Louis  Barracks,  Mo.,  and  Den- 
nison,  Texas,  that  any  epidemic  influence  was  observed.  In  no  way  dur- 
ing the  epidemic  was  cholera  spread  by  movements  of  troops;  but,  in 
every  instance  in  which  it  occurred  among  them  the  cases  were  traced  to 
direct  contact  with  cholera-infected  citizens  living  near  their  quarters. 

Li  tliis  epidemic  the  efficiency  of  active  hygienic  measures  and  a  strict 
system  of  non-intercourse  (which  can  be  most  perfectly  accomplished  in  a 
military  command)  combined  with  a  radical  stamping  out  of  the  disease 
whenever  it  may  occur,  was  fully  demonstrated. 

Late  in  April,  1873,  a  large  body  of  Tennessee  convicts  employed  as 
laborers  on  the  line  of  ]\Iempliis  and  Paducah  railroad  were  attacked  by 
cholera  in  their  camp  about  twenty  (20)  miles  out  of  the  city  of  Memphis. 
On  the  14tli  of  May  following  the  disease  continuing,  although  compara- 
tively but  few  deaths  had  occurred,  the  State  authorities  removed  the 
convicts  from  their  camp  to  the  State  Penitentiary  at  Nashville,  and 
seventy-five  convicts,  the  entire  party  suffering  "/rom  diarrlicea,  copious 
watery  stools,  accompanied  in  very  many  cases  with  nausea  and  vomiting,'''  ' 
were  received  in  the  prison,  then  containing  three  hundred  and  fifty  (350) 
healthy  prisoners.  For  the  result  of  this  importation  of  cholera  the  reader 
is  referred  to  my  narrative  of  the  Cholera  Epidemic  of  1871. 

'  Narrative  of  Cholera  Epidemic  of  1873  in  the  U.  S.,  p.  148. 


]^1Q  ASIATIC  CHOLERA. 

On  the  •2'3d  of  May  cholera  escaped  from  the  penitentiary  and  seized 
upon  the  beautiful  city  of  Xashville,  where  to  July  1st,  according  to  the 
statistics  of  Dr.  W.  K.  Bowling,  no  less  than  six  hundred  and  forty-seven 
(64T)  deaths  occurred.  Ash  Barracks,  situated  on  the  northern  suburb  of 
the  city,  was  garrisoned  by  the  16th  IJ.  S.  Infantry,  and  as  the  epidemic 
assumed  such  grave  proportions,  the  troops  were  moved  from  the  barracks 
to  a  camp  at  White  Creek  Springs,  twelve  miles  from  the  city.  All  com- 
munication between  the  camp  and  Xashville,  with  the  exception  of  one  re- 
liable teamster  who  could  be  depended  on  to  obey  all  instructions,  was 
abandoned. '  A  detachment  consisting  of  one  officer  and  eight  enlisted 
men  remained  as  a  guard  at  Ash  Barracks.  The  family  of  the  officer, 
thinking. that  in  the  empty  barracks  they  would  be  perfectly  isolated,  in- 
sisted upon  remaining  with  him.  At  the  camp  no  epidemic  influence  Avas 
observed.  At  Ash  Barracks  a  cholera  death  occurred  in  the  family  of  the 
officer,  and  four  non-fatal  cases  occurred  among  the  enlisted  men. 

To  Chattanooga,  Tennessee,  cholera  vras  carried  from  Xashville  soon 
after  the  disease  became  epidemic  in  the  latter  city,  by  employees  on  the 
Nashville  and  Chattanooga  Railroad.  The  first  local  case  occurred  in  the 
proprietress  of  a  railroad  boarding-house.  On  June  20th  the  disease  Avas 
rapidly  spreading  through  the  city.  Two  companies  of  the  2d  U.  8. 
Infantry  were  stationed  in  barracks  on  the  southeastern  side  of  the  city. 
One  fatal  case  occurred  in  the  command.  It  being  impossible  to  find 
a  suitable  camp  ground,  on  the  recommendation  of  the  medical  officer, 
Asst.  Surgeon  Charles  Styer,  XJ.  S.  Army,  "  that  the  morals  and  hygienic 
condition  of  the  command  could  be  better  preserved  in  the  barracks  than 
at  an  exposed  camp,^'  it  was  determined  to  remain  in  garrison.  Every 
sanitary  precaution  was  adopted  to  prevent  introduction  of  the  disease,  and 
although  one  fatal  case  did  occur,  the  germs  Avere  stamped  out  and~  no 
other  cases  followed  the  introduction.  Dr.  Styer,  in  his  report,  makes  the 
following  statement:  "  During  the  epidemic,  so  far  as  my  recommenda- 
tion Avent,  the  soldiers  and  officers  and  their  families  used  such  mature 
vegetables  and  fruits  as  could  be  obtained  and  properly  prepared  for  the 
table  in  liberal  though  not  excessive  quantity certain  of- 
ficers Avho  could  not  free  themselves  from  the  influence  of  former  teach- 
ings, confined  their  diet  to  ham  and  eggs,  coffee,  bread,  and  so  on,  and 
before  the  diarrhoea  scare  had  subsided,  had  considerable  trouble  chiefly 
from  diarrhoea  in  different  members  of  their  families." 

At  Lancaster,  Kentucky,  on  August  10th  a  man,  Bewley,  Avho  had 
recently  arrived  from  a  cholera-infected  district  in  the  State  of  Tennessee, 
Avas  taken  Avith  cholera  at  the  house  of  a  friend,  Avhere  after  a  lingering 
illness,  presenting  all  the  phenomena  of  a  prolonged  attack,  he  died  on 
the  tAA'elfth  day.  The  excreta  of  this  case  were  not  disinfected,  but  were 
throAvn  upon  the  ground  in  rear  of  dirty  outhouses.  August  14th  a 
negro  who  nursed  BeAvley,  and  on  August  15th,  the  father-in-law  of  Bewley, 
died  of  cholera,  and  a  malignant  epidemic  Avas  instituted.  The  man 
from  Tennessee  lived  until  August  22d,  and  his  death  was  preceded  by 
nineteen  (19)  cholera  deaths,  all  of  Avhich  were  directly  traceable  to  him". 
In  this  local  epidemic,  among  other  most  interesting  demonstrations  of 
cholera  peculiarities  Avas  an  exhibit  of  the  ability  of  the  infectious  princi- 
ple  to  attach  itself   to  inanimate  objects,   from  which  it  can  be  trans- 

'  This  man  Avas  not  permitted  to  associate  with  or  to  Uve  among-  the  men  in 
camp. 


THE  EPIDEMIC   OF   1873.  m 

ferred  to  the  human  organism  with  fatal  effect.  After  Bewley's  death, 
August  23d,  the  family  left  the  house  and  the  room  in  which  the  death 
occurred  remained  closed  until  September  20th,  when  it  was  opened  and 
occupied  by  an  old  lady,  in  whose  person  cholera  was  rapidly  developed 
and  she  speedily  died. 

One  company  of  the  16th  Infantry  was  doing  garrison  duty  at  Lancas- 
ter; the  troops  were  camped  on  high  ground  east  of  and  immediately  ad- 
joining the  town.  August  23d  the  company  drummer  and  his  wife,  who 
lived  in  the  rear  of  the  cai^tain's  quarters  outside  of  the  limits  of  the  camp, 
were  taken  with  cholera  within  an  hour  of  each  other  and  both  died  within 
twelve  hours.  The  clothing  of  this  couple  had  been  washed  by  a  negro 
woman  who  lived  in  the  infected  district,  and  only  a  few  hours  before  tliev 
were  attacked  the  clothing  had  been  returned  to  the  owners,  August 
29th  a  soldier  was  taken  with  cholera  and  died  within  twenty-four  hours, 
and  the  next  day  his  comrade  who  occupied  the  same  tent  and  slept  in  the 
same  bunk  also  died.  One  of  these  men  had  nursed  and  assisted  in 
preparing  for  burial  the  bodies  of  the  soldier  and  his  wife  who  had  died 
on  the  23d.  The  other  was  known  to  have  frequented  negro  cabins  in 
the  infected  districts. 

August  30th  the  troops  were  moved  to  a  new  camp  ground  two  miles 
from  town.  At  this  camp  one  cholera  case  occurred  soon  after  the  re- 
moval, but  recovered. 

At  Lebanon,  Ky.,  the  epidemic  of  1ST3  was  preceded  by  the  occur- 
rence of  several  seemingly  isolated  cases.  July  19,  a  fatal  case  occurred 
in  a  negro  who  had  come  from  an  infected  house  in  Taylor  county,  Ky. 
August  11th,  a  negress,  also  from  the  infected  district  in  Taylor  county, 
died,  and  from  that  date  to  the  18th  several  suspicious  cases  were  known 
to  have  occurred.  From  August  18  to  the  25th  five  (5)  seemingly  isolated 
cases  occurred,  but  all  these  cases  with  one  exception  resided  upon  or  near 
a  small  stream  which  formed  a  drain  for  the  town.  Disinfectants  were 
employed  in  none  of  these  cases.  The  excreta  were  throAvn  into  or  on  the 
bank  of  the  drain,  which  was  at  that  time  almost  dry.  Upon  the  banks 
of  this  small  stream  and  in  the  immediate  vicinity  of  the  houses  in  which 
the  preceding  cases  had  occurred,  was  a  town  well. 

The  Marion  County  Fair,  which  commenced  August  26th,  was  held 
upon  high  and  unwatered  ground.  "Water  from  the  indicated  well  Avas 
conveyed  in  carts  and  wagons  to  the  fair  ground.  August  26th  the 
water  in  the  well  was  low.  August  2Tth  a  violent  rainstorm  deluged  the 
country,  and  this  well,  from  surface  washing,  was  filled  to  overflowing. 
During  August  28th  and  29th  the  attendance  upon  the  fair  was  large. 
August  30th  a  cholera  explosion  occurred,  and  was  at  first  confined  ex- 
clusively to  those  who  had  been  in  attendance  upon  the  fair.  In  all 
quarters  of  the  town  of  Lebanon,  in  the  most  isolated  portions  of  the  sur- 
rounding counties,  cases  of  cholera  occurred  with  surprising  rapidity. 

One  company  of  the  16th  L^.  S.  Infantry  was  doing  garrison  duty  in 
the  toAvn.  They  were  in  comfortable  barracks  on  high  ground,  and  were 
supplied  with  water  from  a  well  which,  fortunately,  was  so  situated  as  to  be 
beyond  suspicion.  As  the  command  was  in  most  admirable  sanitary  con- 
dition, and  as  cholera  was  so  extensively  diffused  over  Marion  county, 
no  advantage  could  be  obtained  by  moving  these  troops.  They  therefore 
remained  in  barracks.  But  one  case  of  cholera  occurred  in  the  command, 
and  that  in  the  person  of  a  married  soldier  who  had  been  permitted  to 


112 


ASIATIC  CHOLERA. 


live  with  his  family  in  the  town.  No  case  occurred  within  the  limits  of 
the  barracks. 

On  the  last  of  May,  1873,  a  case  of  cholera  was  reported  among  the 
troops  at  Monroe,  La.,  and  in  June  another  case  was  reported  at  the  same 
post;  both  of  these  cases  terminated  fatally.  No  cases  occurred  at  Jackson 
Barracks,  or  at  the  garrison  near  the  city  of  Jackson,  Miss.,  although 
cholera  was  epidemic  among  the  citizens  of  New  Orleans  and  Jackson. 

At  the  Cavalry  Depot,  St.  Louis  Barracks,  one  case  of  cholera  occurred 
July  14th,  in  a  recruit  who  had  recently  joined,  and  avIio  died  after  an  ill- 
ness of  about  ten  hours.  Every  precaution  was  taken  by  Surgeon  B.  A. 
Clements,  U.  S.  A.,  owing  to  which  no  other  cases  occurred,  although  a 
marked  tendency  to  choleraic  diarrhoea  manifested  itself.  The  narrative  of 
the  cholera  epidemic  of  1873  contains  a  statement  of  the  sanitary  precau- 
tions adopted,  and  as  those  portions  of  the  city  of  St.  Louis  contiguous 
to  the  barracks  were  cholera-infected,  the  escape  of  the  troops  from  the 
epidemic  is  surely  owing  to  the  precautions  adopted  by  Dr.  Clements. 

But  one  cholei-a  case  Avas  reported  in  1873  among  the  troo])s  serving 
in  Texas,  and  that  one  was  in  the  person  of  a  man  of  the  11th  IT.  S.  Li- 
fantry  while  on  escort  duty  from  Fort  Griffin  at  Denison,  where  the  epi- 
demic existed  in  some  violence. 

The  authorities  upon  which  this  history  has  been  written,  are: 

1.  A  Statistical  Repoi't  on  the  Sickness  and  Mortality  in  the  Army  of  the 
United  States,  prepared  under  the  dii-ection  of  Thomas  Lawson,  M.D. ,  Surgeon- 
General,  Washing-ton,  1840,  and  which  embraces  a  period  of  twenty  years  from 
January,  1819.  to  January,  1839. 

2.  A  Statistical  Report  on  the  Sickness  and  Mortality  in  the  Army  of  tlie 
United  States,  prepared  under  the  dii-ection  of  Brevet  Brigadier-General  Thomas 
Lawson,  Surgeon-General,  by  Richard  H.  Coolidge,  M.D.,  Asst.  Surgeon,  U.  S.  A. 
Washington,  1856,  and  which  embraces  a  period  of  sixteen  years  from  Janviary, 
1839,  to  January,  1855. 

3.  A  Statistical  Report  on  the  Sickness  and  Mortality  in  the  Army  of  the 
United  States,  prepared  under  tlie  direction  of  Brevet  Brigadier-General  Thomas 
Lawson,  Surgeon-General,  by  Richard  H.  Coolidge,  M.  D.,  Asst.  Surgeon,  U.  S.  A., 
Washington,"! 860,  and  which  embraces  a  period  of  five  years  from  January,  1855, 
to  Januarv,  1860. 

4.  C'ii'cular  No.  5,  War  Department,  S.  G.  O.,  Wasliington,  May  4,  1867.  Re- 
port on  Epidemic  Cholera  in  the  Armj'  of  tlie  United  States  during  the  year  1866. 
By  Brevet  Lieut.-Col.  J.  J.  Woodward,  Asst. Surgeon  U.  S.  A.,  Washington,  1867. 

"  5.  Circular  No.  1,  War  Dept.,  S.  G.  O.,  Washington,  June  10,  1868.  Report  on 
Epidemic  Cholera  and  Yellow  Fever  in  the  Army  of  the  United  States  during  the 
year  1867,  by  Brevet  Lieut.-Col.  J.  J.  Woodward,  Asst.  Surgeon,  U.  S.  A.,  Wash- 
ington, 1868. 

"6.  Report  on  Cholera  Epidemic  of  1873  in  the  United  States,  by  Ely  McClellan, 
M.D.,  Asst.  Surgeon,  U.  S.  A.,  Washington,  1875. 


CHOLERA  ON  SHIPBOARD.  ly^ 


CHAPTER  XVII. 

CHOLERA  ON  SHIPBOARD,  i 

The  occurrence  of  epidemic  cholera  on  board  vessels  in  the  U.  S. 
Navy  has  been  so  infrequent  and  the  preventive  means  have  been  so  suc- 
cessfully applied,  that  the  details  of  such  outbreaks  are  meager. 

Medical  Director  A.  C.  Gorgas  reports  that  in  January  1859,  while 
anchored  off  Manila,  in  the  East  Indies,  on  board  the  U.  S.  S.  Germantown, 
an  outbreak  of  cholera  occurred.  Three  cases  made  their  appearance. 
The  first  and  second  cases  died,  the  third  one  recovered,  treatment  having 
been  successfully  applied  during  the  premonitory  diarrhoeal  phenomena. 
Cholera  existed  on  shore  at  the  time,  and  the  three  patients  had  been  on  lib- 
erty. Attention  was  at  once  directed  to  all  cases  in  Avhich  diarrhoeal 
phenomena  were  present,  and  the  greatest  care  was  taken  in  getting  rid  of 
the  excreta,  and  in  the  destruction  of  all  bedding  and  clothing  belonging 
to  the  patients. 

Dr.  Gorgas  also  reports  that  in  March  and  April,  1867,  while  at  Monte- 
video, S.  A.,  on  board  the  U.  S.  S.  Brooklyn,  one  case  occurred,  not  fatal. 
Cholera  existed  on  shore  and  there  had  been  communication  with  the 
shore  by  the  patient.  The  Brooklyn  went  to  sea.  The  usual  preventive 
measures  were  enforced,  and  no  further  cases  occurred. 

Medical  Director  Thomas  J.  Turner  reports  that  in  October,  1867,  at 
the  Navy  Yard,  Philadelphia,  on  board  the  U.  S.  S.  Potomac,  an  outbreak 
of  epidemic  cholera  occurred.  The  officers  and  crew  of  the  Potomac  aggre- 
gated 300  men.  There  were  65  cases  of  the  disease  with  32  deaths.  No  cases 
of  cholera  were  known  to  exist  on  shore  in  the  city  of  Philadelphia,  either 
before,  at  the  time,  or  afterward.  The  origin  of  the  disease  is  ascribed 
to  the  use  of  the  Delaware  river  water,  and  the  position  of  the  vessel  in 
the  river  a  short  distance  from  the  outlet  of  a  main  sewer  lends  credence 
to  this  supposition.  The  measures  used  to  prevent  the  spread  were  as 
follows:  1.  Stopping  at  once  the  use  of  the  river  water  for  all  purposes. 
2.  Isolation  of  all  those  affected  with  the  disease.  3.  Prompt  attention  to 
all  cases  presenting  any  diarrhoeal  phenomena.  4.  The  immediate  removal 
of  all  ejecta  and  dejecta.  5.  Free  ventilation,  cleanliness  and  dryness  of 
the  vessel.  6.  The  free  use  of  limewash,  carbolic  acid  and  ferric  sul- 
phate in  solution.  The  epidemic  was  ended  within  60  hours  from  its 
outbreak.  Its  arrest  was  attributed  to  the  prompt  measures  instituted  by 
this  officer  and  their  military  enforcement. 

Dr.  Turner  formulated  for  the  use  of  the  National  Board  of  Health 

'  Memoranda  kindly  furnished  by  the  Bureau  of  Medicine  and  Surgery,  U.  S. 
Navy  Department. 

8 


X14  ASIATIC   CHOLERA. 

(and  his  suggestions  were  published  in  the  Sanitarian  for  June,  1883), 
preventive  measures  to  be  applied  to  vessels  in  the  event  of  an  outbreak 
of  cholera  at  sea: 

"  Cholera  at  sea — Isolate  the  patient,  receive  all  the  dejecta  in  receptacles 
partially  filled  with  sea-water,  or,  if  in  a  steamer,  in  such  receptacles  partially 
filled  with  fresh  coal  ashes  from  the  fire-room,  and  then  throw  the  mass  over- 
board. The  ashes  contain  iron  salts,  and  in  so  far  as  the  iron  salts  are  present, 
are  more  or  less  disinfectant.  Burn  all  clothing,  bedding  or  like  articles  soiled  by 
any  of  the  ejecta.  Bury  overboard,  and  early.  If  the  decks  should  be  soiled  with 
the  ejecta,  lime  wash,  and  afterward  scrape,  and  burn  the  scrapings.  InsiDectthe 
water  suppl5\  Boil  ail  used  for  drinking  or  culinary  purposes.  Use  distilled 
water  if  practicable.  Inspect  food  and  cooking.  Inspect  all  passengei's  and  crew 
to  discover  sj-mptoms  of  premonitory  diarrhoeal  phenomena.  IMore  than  one 
movement  of  the  bowels  per  diem,  under  the  circumstances,  to  be  regarded  as 
suspicious,  and  the  person  so  affected  kept  under  obsei'vation.  The  personal 
cleanliness  of  ail  hands  to  be  insisted  upon.  The  use  of  the  cholera  belt  of  flan- 
nel to  be  enforced.  The  cleanliness,  diyness  and  ventilation  of  all  inhabited 
apartments  to  be  secured." 

In  the  years  1877-78-79,  during  the  prevalence  of  epidemic  cholera 
at  numerous  ports  on  the  Asiatic  station,  no  cases  occurred  on  any  of  the 
vessels  composing  the  U.  S.  Squadron  on  that  station,  and  there  was  a 
notable  decrease  of  all  diseases  of  the  alimentary  system  attended  with  flux. 
This  freedom  from  such  disease  movement  is  ascribed  to  the  use  of  dis- 
tilled water  for  all  purposes  on  board  the  vessels  on  the  station.  It 
must  be  observed  that  the  distilled  water  used  on  naval  vessels  is  obtained 
by  the  distillation  of  sea-water.  Xo  water  from  the  shore  should  be  used 
on  vessels  provided  with  a  distilling  ajjparatus,  and  if  necessity  requires 
the  use  of  Avater  from  shore,  such  Avater  should  be  boiled,  filtered  and 
then  aerated.  This,  Avith  the  preserA'ation  of  perfect  dryness  and  cleanli- 
ness of  the  A^essel,  affords  the  best  means  of  protection. 

The  medical  records  of  the  U.  S.  S.  LackaAA'anna  report  the  appear- 
ance of  cholera  on  board  that  vessel  Avhile  at  Calcutta  in  December, 
1873,  Avhich  was  ascribed  to  the  use  of  bad  water.  There  Avere  5  cases 
and  2  deaths.  The  disease  existed  in  the  city  at  the  time,  and  on  the 
banks  of  the  Ganges  and  Hoogly  rivers.  The  prompt  departure  of  the 
vessel,  with  isolation  of  the  sick,  and  the  usual  measures  of  cleanliness  and 
disinfection,  terminated  the  outbreak  on  board. 

Surgeon  M.  L.  Ruth,  U.  S.  Xavy,  reports  from  memory  an  outbreak 
of  cholera  on  the  passenger  ship  Florida,  on  her  voyage  from  Havre  to 
NcAV  York  in  the  fall  of  1866.  The  Florida,  a  scrcAV  steamer  of  about 
3,000  tons,  left  Havre  during  the  latter  part  of  October,  of  the  year  men- 
tioned, with  a  passenger  list,  including  crcAv  and  officers,  approximating 
600  souls.  After  six  days  at  sea  epidemic  cholera  appeared.  There  were 
157  cases  Avith  45  deaths.  The  disease  exhausted  itself  Avithin  tAvelve  days. 
No  cases  of  cholera  Avere  known  to  exist  at  Havre  at  the  time  of  departure. 
The  ship  Avas  overcroAvded.  "Water  in  the  tanks  that  Avere  opened  on  the 
fifth  day  had  been  submerged  in  the  tanks,  and  had  also  been  taken  from 
an  infected  source,  as  was  afterward  demonstrated.  It  Avas  bad  and 
brackish. 

The  sailing  ship  Mercury,  Avhich  left  HaATe  a  day  or  two  subse- 
quent to  the  Florida,  and  Avhose  tanks  had  been  filled  from  the  same 
source,  had  cholera  appear  Avhen  six  days  out,  Avith,  it  was  stated,  thirty 
deaths.  As  the  Florida's  tanks  had  been  filled  six  Aveeks  before  those  of 
the  Mercury,  and  as  no  cases  Avere  known  to  exist  at  HaATe  i^revious  to 
the  sailing  of  these  ships,   Dr.   Ruth  infers  that  perhaps  from  forty  to 


CHOLERA  ON  SHIPBOARD.  125 

fifty  days  is  the  time  necessary  for  the  development  of  the  cholera  germ 
in  water,  especially  as  it  appears  that  in  a  few  days  after  the  departure  of 
these  ships  cholera  appeared  at  Havre. 

On  board  the  Florida  there  was  no  distilling  apparatus,  and  when 
Dr.  Euth  took  charge,  coincident  with  the  isolation  of  the  sick,  as  far  as 
practicable  the  further  use  of  water  from  the  tanks  was  arrested,  and  only 
after  boiling,  filtration,  aeration  and  mixing  with  red  wine,  was  it  allowed 
to  be  used.  Attention  was  paid  to  the  checking  of  the  premonitory  diar- 
rhoea. Xo  cabin  passengers  were  attacked.  The  dead  were  buried  with- 
out delay.  After  beginning  the  use  of  the  filtered  and  boiled  water  the 
disease  abated. 

Dr.  Ruth  reports  that  in  the  late  cruise  of  the  Essex  around  the 
world  the  use  of  distilled  water  appears  to  have  secured  almost  complete 
exemption  from  all  forms  of  bowel  disturbance. 

Cholera  appeared  on  board  the  U.  S.  S.  Frolic,  at  Cherbourg, 
France,  October  16th  1866;  7  cases  occurred,  with  5  deaths,  among  men 
who  had  been  on  shore.  The  crew  consisted  of  116  persons.  October 
26tli  the  sick  were  transferred  to  the  hospital  ship  Fort.  The  Frolic 
was  fumigated  by  burning  sitlphur,  and  no  more  cases  occurred. 

The  recent  statistical  reports  of  the  health  of  the  British  navy  (1883) 
show  similar  experiences  to  our  own.  Their  vessels  on  the  East  India 
station  have  been  attacked  by  cholera  from  the  use  of  bad  Avater  by  the 
crew  on  shore.  The  Espoir  had  8  cases  with  5  deaths  at  Foochow, 
China.  "  The  men  who  were  attacked  had  partaken  of  lemonade  made 
by  the  Chinamen,  the  water  for  which  was  drawn  from  a  well  in  the  most 
infected  part  of  the  city. "  The  vessel  proceeded  to  Hong  Kong  without 
any  other  cases  appearing,  and  was  thoroughly  disinfected  there. 

The  Flying  Fish  gunboat  had  7  cases  with  3  deaths  at  Chefoo, 
China,  where  the  crew  were  on  shore  on  liberty.  The  vessel  put  to  sea, 
and  was  cleansed  and  fumigated  with  the  result  apparently  of  ending  the 
attack:  but  on  reaching  the  Corea,  two  more  cases  occurred.  The  crew 
were  then  landed  on  a  barren  island,  under  tents,  until  a  more  thorough 
cleansing  of  the  vessel  was  had  and  sulphur  was  burned  in  the  hold  and 
storerooms  below.     Xo  more  cases  occurred. 

"Willi  cholera  prevailing-,  as  itcUd,  in  Chefoo,  when  the  habits  of  the  natives 
are  known,  it  is  not  difficult  to  trace  the  cause  of  the  outbreak.  The  vegetables 
grown  for  the  use  of  the  town,  among  which  are  lettuce,  cabbag-es  and  pumpldns, 
are  watei-ed  A\ith  the  fresh  excreta  of  the  inhabitants  diluted  A\-ith  water;  and 
the  bread  is  made,  and  the  milk,  which  is  very  plentiful,  adulterated,  with  the 
water  from  '  one  of  the  worst'  wells  in  this  filthy  town.  To  the  milk  the  medical 
officer  specially  attributes  the  disease;  both  the  men  who  died  of  cholera  were  ex- 
ceptionally larg:e  milk  drinkei-s,  and  all  the  wardi'oom  officei-s,  who  also  drank 
milk  freely,  suffered  from  diarrhoea." 

The  following  sanitary  precautions  in  regard  to  cholera  were  established 
by  the  British  Admiralty,  August  3,  1866: 

"  There  appears  to  be  little  doubt  in  the  present  state  of  knowledge  with  re- 
spect to  this  disease,  and  hope  of  successfidly  combating  it  is  veiy  much  limited 
to  its  earliest  stage,  that  of  the  premonitory  diarrhoea;  and  it  is  to  the  fact  that 
patients  rarelj'  present  themselves  to  the  medical  officers  until  that  stage  is  past, 
that  the  great  mortality  it  occasions  is  attributable.  As  no  amount  of  experience 
on  the  part  of  the  men  themselves,  and  no  advice  given  them,  appears  to  be  of  anj' 
value  in  inducing  them  to  present  themselves  at  an  earlier  period,  it  Avill  be  neces- 
sary to  institute  such  measures  as  may  permit  of  a  daily  knowledge  of  the  general 
state  of  health  of  the  individual  members  of  the  ship's  company,  and  of  the  men 
in  barracks,  being  obtained.     For  this  purpose  my  Lords  direct — 


|]^g  ASIATIC  CHOLERA. 

"1.  That  the  petty  officers  of  messes  be  desired  to  exercise  an  iin obtrusive 
watchfulness  over  the' men  composing  tlieir  messes;  that  they  report  to  the  medi- 
cal officer  any  man  whom  they  may  know,  or  have  reason  to  suspect,  to  be  laboring 
under  diarrhoea,  or  who  may  appear  to  be  in  ill-health;  and  that  it  be  impressed 
upon  them  that  by  evincing-  an  intelligent  interest  in  tliis  direction  they  will  do 
much  to  prevent  any  outbreak  of  cholera  on  board. 

"2.  Once  daily,  at  least,  at  a  tiine  when  the  majority  of  the  men  are  in  their 
messes,  a  medical  officer  shall  go  round  the  different  mess-decks  and  ascertain 
from  the  petty  officers  of  messes  whether  there  is  any  one  requiring  his  attention, 

' '  3.  The  officers  of  divisions,  when  inspecting-  their  men,  shall  take  notice  of 
anj'  man  who  may  appear  to  be  iia  ill  health,  and  shall  cause  him  to  be  at  once 
taken  to  the  sick-l)ay  and  reported  to  the  surgeon. 

"  4.  Twice  daily  "at  least,  the  head  shutes,  as  well  as  the  shutes  of  the  different 
water-closets  in  the  ship  wliich  are  much  used,  shall  be  washed  down  with  a  solu- 
tion of  cliloi'ide  of  zinc,  in  the  pi'oportion  of  one  part  of  Burnett's  solution  of 
chloride  of  zinc  to  thirty  of  water,  or  chloride  of  lime  may  be  freely  used  instead, 
and  instructions  shall  be  given  to  the  captain  of  the  head  to  report  to  the  surgeon 
anjr  man  who,  from  making-  repeated  use  of  it,  may  be  svispected  to  be  laboi"ing 
luader  diarrhoea. 

"  5.  Should  cholera  have  established  itself  on  board  any  ship,  the  utmost  care 
is  to  be  taken  that  the  choleraic  discharges,  whether  from  the  stomach  or  bowels, 
are  largely  mixed  witii  the  solution  of  the  chloride  of  zinc  or  some  other  disinfect- 
ant before  they  are  thrown  away,  and  that  any  clotlaing  or  bedding  contaminated 
with  tiie  discharges  be  destroyed. 


PART  SECOKD. 


THE  ETIOLOGY  OF  CHOLERA 


BY 


EDMUND    C.    WENDT,    M.D., 

OF  NEW  YORK. 


LEADING  THEORIES.  H^ 


CHAPTER   X^^III. 

GENEEAL  RETklARKS  AND  SOME  LEADING  THEORIES  ON  THE 
NATURE    OF  CHOLERA. 

I]sr  attempting  to  set  forth  the  causation  of  cholera  in  as  complete  and 
satisfactory  a  manner  as  is  compatible  with  our  actual  knowledge  of  the 
subject,  it  will  not  be  possible  to  avoid  entering  into  the  land  of  theory 
and  speculation.  There  is  probabh'  no  other  disease  the  etiology  of  which 
has  been,  and  continues  to  be,  so  much  in  dispute  as  that  of  cholera. 
Heated  discussions  and  prolonged  controversies  concerning  its  essential 
nature  have,  indeed,  marked  the  history  of  the  disease  from  its  first  ap- 
pearance among  us.  At  the  present  day  the  vast  majority  of  competent 
writers  agree  that  Asiatic  cholera  must  have  a  special  and  distinct  exciting 
cause.  Ordinary  agencies,  general,  local  and  individual,  without  the 
addition  of  this  ultimate  and  essential  something,  are  utterly  inadequate 
to  produce  it.  In  other  words,  Asiatic  cholera  is  always  the  result  of 
specific  infection.  And  from  recent  inquiries  it  seems  probable  that  the 
carriers  of  the  infection  are  certain  particular  micro-organisms  discovered 
by  Koch,  and  now  generally  known  by  the  name  of  comma-bacilli.  It 
may  be  well  to  admit  at  the  outset  that  unless  we  accept  Koch's  theory, 
the  special  and  essential  exciting  cause  of  epidemic  cholera  is  still  un- 
knoAvn.  But  before  presenting  an  account  of  the  German  mycologist's 
doctrine,  which  assumes  the  micro-parasitic  origin  of  the  disease,  it  will 
be  both  interesting  and  instructive  to  review  some  of  the  leading  theories 
that  have  been  advanced  regarding  the  nature  of  cholera. ' 

The  Water-Miasm  Theory  of  Bayer. — In  1832,  M.  Bayer^  pro- 
pounded a  theory  tracing  the  disease  to  a  miasm  which  was  contained  in 
the  water  of  tardy  rivers  and  boggy  pools.  These  pools  and  marshes  lib- 
erate the  miasm  during  the  evaporation  of  water;  the  miasm  then  be- 
comes mixed  with  the  atmosphere,  and  thus  produces  the  disease. 

In  countries  surrounded  by  mountains  and  abounding  in  lakes  and 
marshes,  Bayer  asserts  that  cholera  prevails  most  severely.  On  the  other 
hand  in  countries  through  which  streams  pass  with  some  rapidity,  where  no 

'  It  is  as  unnecessary  as  it  would  be  unprofitable  to  examine  critically  all  the 
multitude  of  etiological  views  on  cholera  that  have  at  one  time  or  another  com- 
manded the  attention  of  the  profession,  nor  lias  it  been  deemed  adx-isable  to  enter 
into  an  elaborate  discussion  of  all  those  doctrines  which  are  here  reproduced. 
In  connection  with  most  of  them,  however,  sufficient  comment  will  be  made  to  fully 
acquaint  the  reader  with  the  estimation  placed  by  the  editor  upon  them.  The 
opinions  of  a  few  writers  will  be  quite  briefly  summarized  without  comment,  the 
reader  being, of  course,  at  liberty  to  draw  his  own  conclusions.  On  the  other  hand, 
the  writings  of  some  authors  will  receive  veiy  ample  attention. 

-  Henke's  Journal  of  State  Medicine  for  1833  (Macnamara). 


120 


ASIATIC  CHOLERA. 


stagnant  waters  are  found,  and  where  the  foundation  is  rocky  and  the  soil 
sandy,  cholera  has  not  made  much  impression. 

The  power  of  the  infectious  matter  evolved  from  the  water  with  which 
it  had  combined  is  increased  by  the  admixture  of  marsh  miasms.  So 
that,  according  to  Bayer,  the  water  of  rivers  will  carry  the  matter  in  this 
compound  state,  and  evolve  it  in  different  quantity  and  varying  degrees 
of  intensity,  according  to  the  activity  of  the  powers  causing  its  disengage- 
ment. 

The  theory  of  Bayer  rests  on  assumptions  and  not  facts.  It  has  been 
discarded  as  untenable.  Xevertheless  it  shows  that  contaminated  water 
was  early  recognized  as  an  active  agent  in  the  dissemination  and  j^ropaga- 
tion  of  cholera. 

The  Fermentation  Theory. — An  etiological  doctrine  frequently 
advanced  may  be  called  the  old  fermentation  theory.  According  to  this 
the  action  of"  the  cholera  poison  is  similar  to  the  fermentative  process. 
The  germ  of  the  disease  is  not  in  itself  active.  It  must  first  undergo  a 
change  in  which  gaseous  by-products,  the  true  poison,  are  evolved.  This 
process  was  assumed  to  occur  in  the  ground,  in  such  places  as  presented 
suitable  conditions,  and  where  a  mixture  of  the  "cholera  principle^'  with 
the  peculiar  "soil  principle"  could  be  effected.  It  was  compared  to  alcoholic 
fermentation,  in  which  an  indifferent  fluid  containing  sugar  is  changed 
into  alcohol  through  the  action  of  a  ferment.  A  catal}i;ic  force  was  sup- 
posed to  be.  the  agent  causing  such  changes.  The  fungi  of  fermentation 
were  unknown  at  that  time,  and  hence  this  theory  was  a  very  ingenious 
hyjwthesis,  lacking  the  support  of  actual  knowledge  concerning  the  true 
nature  of  fermentation.  As  will  appear  further  on,  Pettenkofer,  even  to 
the  present  day,  upholds  a  theory  that  bears  a  decided  resemblance  to  this 
old  fermentation  doctrine. 

The  Excrementitious-Poison  Theory  of  Snow.' — In  1849  Dr.  J. 
Snow  asserted  that  the  poison  of  cholera  being  swallowed  acts  directly  on  the 
intestinal  mucous  membrane.  At  the  same  time  it  is  reproduced  within 
the  body  and  passes  out,  much  increased  in  quantity,  with  the  discharges. 
Afterward  these  discharges,  chiefly  by  becoming  mixed  with  the  Avaters 
of  rivers  and  wells,  reach  the  alimentary  canals  of  other  persons,  and  give 
them  the  same  disease. 

According  to  Snow,  the  methods  of  propagation  of  cholera  are  four  in 
number: 

1st.  Moist  excreta  on  clothes  and  bedding  of  infected  persons  may 
be  carried  by  the  vapor  of  water  and  enter  the  nostrils  and  mouth  and  be 
swallowed.  2d.  Dry  excreta  on  infected  clothing  may  he  wafted  a  short 
distance  by  the  air  when  the  clothing  is  moved  or  unfolded.  3d.  Nurses 
and  those  who  attend  the  sick  may  introduce  the  poison  into  their  system 
by  not  washing  their  hands  before  taking  food.  4th.  Utensils  used  by  the 
sick  and  not  j^roperly  cleansed  may  also  contain  the  germs  of  the  disease. 

Snow's  writings  show  that  he  Avas  a  careful  observer,  and  although  he 
remained  in  ignorance  of  the  true  nature  of  the  infecting  agent,  he  never- 
theless should  receive  the  credit  of  having  ascertained  the  manner  of  its 
behavior,  and  a  favorite  mode  of  its  dissemination. 

The  Cholerine  Theory  of  Farr. — Dr.  W.  Farr,  in  1852  stated  that 
the  disease  was  caused  by  a  specific  organic  matter,  the  z3'motic  principle 
of  cholera,  which  he  called  cholerine.     He  believed  that  "  a  variety  of  that 

'  On  the  Mode  of  Communicating  Cholera.     By  J.  Snow.    London,  1849. 


LEADING  THEORIES.  ]^9J^ 

matter  was  2:)ro(lucecl  iu  India  in  certain  unfavorable  circumstances;  it  had 
the  property  of  propagating  and  multiplying  itself  in  air,  or  water,  or  food, 
and  of  destroying  men  by  producing  in  successive  attacks  a  series  of  j^henom- 
ena  which  constitute  Asiatic  cholera."  He  says:  "  That  cholerine  is  an  or- 
ganic matter  cannot,  I  think,  be  doubted  by  those  who  have  studied  the 
Avhole  of  its  phenomena  and  the  general  laws  of  zymotic  disease.  The  great 
questions  remain — Is  cholerine  produced  in  the  human  organization  alone, 
and  propagated  by  excreted  matter  ?  Is  it  produced  and  propagated  in 
dead  animal  or  vegetable  matter,  or  mixed  infusions  of  excreta  and  other 
matters  out  of  the  body  ?  Is  it  propagated  through  water,  through  air, 
through  contact,  or  through  all  these  channels?"*  He  himself  was 
unable  to  answer  these  queries.  It  appears,  therefore,  that  Farr's  views 
were  rather  unsettled  and  quite  hypothetical.  But  as  far  as  they  went 
they  were  decidedly  ingenious  and  suggestive. 

Kiehl's  Theory. — A  German  physician,  Kiehl,^  who  practiced  in  India 
for  many  years,  believed  the  cause  of  cholera  to  be  a  contagion  first  formed 
in  the  human  organism  itself,  altogether  independent  of  climatic  or  other 
external  influences.  He  says  that  the  cholera  of  the  present  day  arose  in 
Jessore  in  1817,  and  was  thence  spread  by  the  flight  from  Jessore  and  by 
Hastings'  army  through  Bengal.  It  gained  access  to  Europe  only  through 
human  intercourse,  and  Avas  certainly  not  generated  there.  "  Prior  to 
1817  cholera  existed  only  in  India  in  endemic  form,  but  at  that  time  its 
nature  underwent  a  complete  change.  The  disease  now  became  epidemic, 
and  this  metamorphosis  is  to  be  accounted  for  only  by  some  alteration  in 
the  physical  condition  of  the  natives.  The  latter  consisted  in  blood-poison- 
ing induced  by  breathing  vitiated  air,  the  result  of  overcrowding.  It  oc- 
curred at  the  time  of  the  fair  at  Jessore,  during  a  season  of  deficient  rain- 
fall, when  there  was  a  scarcity  of  drinking  water  and  a  failure  in  the  rice 
crop.  In  Europe  cholera  is  never  autochthonous,  but  is  spread  by  a 
contagion  existing  in  the  breath  or  in  the  dejections  of  cholera  patients. 

Comment  on  Kiehl's  theory  is  hardly  called  for.  Yet  it  will  be  seen 
that,  with  certain  modifications,  his  blood-poison  theory  received  at  dif- 
ferent times  a  Avide  currency,  and  that  even  to-day  the  search  for  j^oisons 
in  the  blood  of  cholera  patients  continues.  The  similarity  between  the 
poison  theory  of  Snow  and  the  much  later  doctrine  of  Kiehl  is  apparent, 
as  is  also  its  resemblance  to  the  views  of  Johnson,  that  will  next  occupy 
our  attention. 

Johnson's  Blood-poison  Theory. — This  theory  was  at  one  time 
extensively  accepted  by  physicians.  But  on  the  showing  of  competent 
and  impartial  writers  like  ]\Iacnamara,  Simon  and  others,  it  appears  quite 
untenable.  In  point  of  fact,  at  the  present  day  it  has  but  f cav  supporters. 
According  to  Dr.  George  Johnson,  then, ^absorption  of  a  miasmatic  poison 
results  in  a  primary  alteration  of  the  blood;  that  in  turn  leads  to  the 
characteristic  phenomena  of  an  attack  of  cholera. 

Johnson  believes  that  there  is  much  evidence  to  show  that  the  poison 
of  cholera  may  be  inhaled  as  well  as  SAA^allowed.  If  inhaled,  it  must  first 
enter  the  blood  before   it  can  reach  the  alimentary  canal. 

In  a  large  number  of  cases  of  malignant  cholera,  constitutional  disturb- 
ances precede  the  local  intestinal  manifestations;  in  other  Avords,  the  disease 

'  Report  on  the  Mortality  of  Cholera  in  England  in  1848-49.     By  Dr.  W,  Farr. 
^  Uber  den  Ureprung-  und  die  Verhiiting  der  Seuchen.    Erleutert  durch  das  Bei- 
spiel  der  ansteckenden  Cholera.     Von  W.  F.  P.  Kiehl.     Berlin,  1865. 
^  Notes  on  Cholera.     By  Dr.  G.  Johnson,  London,  1866. 


122 


ASIATIC  CHOLERA. 


has  a  period  of  incubation  marked  b}'  malaise.  The  copious  discharges 
from  the  intestines  are  the  efforts  of  nature  to  eliminate  the  poison  from 
the  system  and  thus  to  cause  recovery,  and  consequently  if  the  secretion 
be  checked,  the  risk  of  fatal  collapse  is  greatly  increased.  The  albuminous 
condition  of  the  urine  points  to  blood-poisoning,  the  foetus  in  utero  has 
been  known  to  succumb  to  the  poison,  and  characteristic  discharges  have 
then  been  discovered  in  its  alimentary  canal. 

Johnson  also  maintains  that  the  specific  poison  of  cholera  exercises  an 
influence  on  the  arterioles  of  the  lungs  and  causes  spasm  of  the  muscular 
coats  of  these  vessels.  This  leads  to  the  imperfect  aeration  of  the  blood, 
and  there  is  produced  a  venous  congestion  of  the  right  side  of  the  heart, 
and  therefore  systemic  poisoning. 

Relying  on  ^all  these  facts.  Dr.  Johnson  administers  purgatives,  such 
as  castor-oil,  etc.,  in  order  to  assist  the  action  of  nature  in  draining  away 
the  specific  poison. 

The  results  of  the  purgative  plan  of  treatment  as  pursued  by  Johnson 
and  his  followers  have  not  been  such  as  to  place  his  claims  on  the  assured 
basis  of  empirical  truth,  whatever  theoretical  objections  might  be  raised 
against  the  acceptance  of  the  theory. 

Moreover,  Simon  has  pointed  out  that  all  the  well-established  facts  of 
cholera  are  explicable  on  the  assumption  of  a  secondary  blood-infection, 
resulting  from  the  diseased  condition  of  the  bowels.  Primary  blood-poison- 
ing Simon  rejects  as  an  untenable  theory. 

He  says: 

"  I  do  not  find  it  proven,  nor  do  I  see  any  tlieoretical  convenience  in  taldng  for 
granted  that  cholera  begins  as  an  active  blood  change  capable  of  producing  pri- 
mary collapse.  The  facts,  so  far  as  I  know  them,  can  all  be  reconciled  with  the 
belief  that  cholera  begins  as  bowel  disease,  producible  by  direct  contagion,  without 
even  a  passive  intervention  of  the  blood." 

Further  on  he  writes: 

"In  questioning  the  fact  of  a  primarj'  blood-poisoning  in  cholera,  I,  of  coui-se, 
do  not  intend  to  denj^  that  the  blood  during  cholera  is  poisoned.  From  our  ear- 
liest knowledge  of  the  disease  it  has  been  on  recoi-d  that  where  pregnant  women 
have  cholera  the  intrauterine  offspring  almost  invariably  dies."  ' 

The  cause  of  the  infant's  death,  he  holds,  has  been  shown  to  be  true 
choleraic  infection.  Finally  in  the  "  Ninth  Eeport  to  the  Privy  Council," 
London,  1867,  Mr.  Simon  remarks  that,  '"'the  notion  of  a  primary  blood- 
poison  in  cholera  seems  tending  more  and  more  to  be  superseded." 

Macnamara  also  takes  up  Johnson's  conclusions  seriatim  and  points  out 
that,  they  do  not  accord  with  the  facts,  recognized  as  such  by  the  best 
authorities. 

It  may  be  stated,  however,  that  Johnson,  in  spite  of  these  and  many 
other  adverse  criticisms,  still  adheres  to  his  former  views.  And  quite  re- 
cently, before  the  Eoyal  ]\Iedical  and  Chirurgical  Society,  he  read  an  elabo- 
rate argument  in  support  of  his  doctrine.* 

TheTheoryofllisch. — Decomposing-Dejections. — Eisch,' an  ex- 
perienced Russian  practitioner,  maintained  that  the  contagium  of  cholera  is 
not  given  off  directly  from  the  bodies  of  the  sick,  but  is  formed  by  the  decom- 

1  Report  on  Pviblic  Health  for  1866. 
•^  The  Lancet,  March  28,  1885. 

» Untersuchungen  tiber  die  Entstehung  und  Verbreitung  des  Cholera-Con- 
tagiums,  etc.     Von  F.  Ilisch,  St.  Petei'sburg,  1866. 


LEADING  THEORIES.  12.?' 

position  of  their  dejections,  when  exposed  to  the  action  of  the  air.  After  the 
introduction  of  the  contagium  the  epidemic  arises  independently  of  any  tel- 
hiric  influences,  provided  only  the  diffusion  of  the  poison  is  possible,  and 
under  all  those  conditions  which  especially  favor  putrefactive  processes. 
"When  the  cholera  contagium  comes  in  contact  with  putrefying  substances 
a  fresh  supply  may  be  produced  by  their  decomposition.  Whatever  hinders 
putrefaction  and  decomposition  (low  temperature,  abstraction  of  water  and 
disinfection),  hinders  also  the  further  production  of  the  cholera  contagium. 
This  contagium  may  be  carried  from  the  sick  to  the  well  by  the  air,  by 
water,  or  by  handling  objects  soiled  with  cholera  dejections. 

The  views  of  Ilisch  were  at  no  time  regarded  Avith  much  favor  by  his 
confreres  in  Russia.  Yet  it  will  be  seen  that  they  are  not  unlike  some  of 
the  more  modern  conceptions  on  the  nature  of  cholera,  as  explained  in  the 
writings  of  authors  of  different  nationalities.  Even  so  comj)etent  an 
authority  as  Macnamara  has  propounded  a  theory  that  bears  an  unmistak- 
able resemblance  to  the  views  of  Ilisch. 

Bryden's  Monsoon  Theory. — Dr.  Bryden  supposed  the  cholera 
contagium  to  be  a  miasm.  He  asserted  that  this  miasm  grew  and  flour- 
ished only  in  lower  Bengal,  in  the  delta  of  the  Ganges  and  Brahmapootra. 
Here  the  disease  had  its  endemic  home.  It  was  carried  hence  periodically 
in  ej^idemic  waves  by  the  moist  winds  of  the  monsoon.  He  did  not  deny 
that  cholera  might  be  propagated  through  human  intercourse,  but  still  he 
regarded  the  atmosphere  as  the  main  channel  of  its  diffusion. 

Eegarding  the  ultimate  cause  of  the  disease  he  had  no  definite  opinion. 
Still,  he  thought  it  resembled  in  its  behavior  an  organized  vital  body.  It 
had  periods  of  growth,  existence,  decay,  revitalization,  and  final  death. 
Time,  place  and  atmospheric  conditions  were  all  so  many  factors  that  in- 
fluenced its  appearance  and  spread.  The  germs  lay  hidden  in  the  ground. 
Under  favoraljle  local  and  atmospheric  conditions  their  vitality  was  roused 
into  full  play.     Currents  of  wind  then  propagated  the  active  poison. 

He  maintained  that  the  destructive  epidemics  were  due  to  an  "  over- 
flowing of  the  endemic  boundaries  "  of  the  disease,  as  indicated  above.  It 
may  be  remarked  that  Bryden's  views  accord  in  the  main  with  those  of 
Dr.  Beasley,  of  Midnapore  {Rep07't  on  Cholera,  18G6-68). 

The  theory  of  Bryden  is  not  tenable.  Tested  by  the  actual  experience  of 
numerous  epidemics,  it  fails  completely  to  afford  an  adequate  explanation 
of  the  origin  and  propagation  of  cholera.  Kiichenmeister '  has  taken 
the  pains  to  show  that  not  one  of  Bryden's  conclusions  regarding  the  mon- 
soons as  carriers  of  cholera  is  in  harmony  with  positive  facts. 

The  Ozone  Theories. — A  German  writer,  Stiehmer,  advanced  the 
theory  that  cholera  was  due  to  a  deficient  supply  of  ozone  in  the  atmos- 
phere, and  the  same  theory  in  a  somewhat  modified  form  was  revived  at  a 
later  period  by  Lender,  also  a  German.  Other  writers  have  published 
similar  views. 

The  ozone  theories  were  at  one  time  subjects  of  serious  consideration 
on  the  part  of  the  medical  profession.  They  are  merely  mentioned  here 
as  illustrating  the  vagaries  into  which  physicians  have  fallen  with  regard 
to  the  etiology  of  cholera. 

The  Organic-Dust  Theory  of  Von  Gietl. — In  a  monograph  on 
cholera  embodying  the  results  of  experience  gained  in  many  ejaidemics  Yon 

'  Handbiich  der  Lehre  von  der  Verbreitung  der  Cholera,  etc.  Von  Dr.  F. 
Kiichenmeister.     Erlangen,  1872,  pp.  373-304. 


124.  ASIATIC  CHOLERA. 

Gietl '  announced  liis  conviction  that  the  cholera  virus  was  contained  in 
the  intestinal  discharges,  and  that  it  was  capable  of  speedy  reproduction. 
He  also  showed  that  persons  having  diarrhoea,  without  experiencing  any 
particular  pain  or  discomfort,  might  nevertheless  start  an  epidemic.  He 
mentions  the  fact  that  many  toxic  substances  may  produce  choleraic  symp- 
toms. A  differential  diagnosis  based  on  symptoms  is  not  possible.  Viru- 
lent Asiatic  cholera  can  only  be  recognized  as  such  when  several  cases  occur 
in  quick  succession.  The  cholera  poison  having  entered  the  body  from 
without,  abstracts  large  quantities  of  fluid  from  the  system  of  the  patient, 
by  its  action  upon  the  gastro-intestinal  mucous  membrane.  It  retards  the 
flow  of  blood  and  the  current  of  vital  juices,  and  finally  stops  their  move- 
ments completely.  These  disturbances  explain  the  terrible  phenomena  of 
the  disease. as  well  as  the  speedily  fatal  issue.  Organic  dust  is  the  carrier 
and  disseminator  of  the  cholera-poison.  Like  all  other  dust,  the  cholera-dust 
does  not  enable  us  to  recognize  the  virus  through  any  characteristic  shape 
of  its  own.  We  find  the  same  condition  of  things  in  other  diseases;  for 
we  are  unable  Avith  the  aid  of  chemistry  and  microscopy  to  differentiate 
healthy  pus  from  that  tainted  with  farcy,  variola,  or  syphilis. 

Yon  Gietl  was  a  close  student  and  careful  observer.  Yet,  m  spite  of 
all  this,  as  well  as  his  extended  experience,  he  was  led  into  the  gross  error 
of  formulating  a  hAq^^othesis  that  receives  no  support  even  from  his  own 
observations.  It  seems  strange  that  he  should  take  refuge  in  so  baseless  a 
view  as  his  dust-theory,  after  having  clearly  demonstrated  the  infectious 
nature  of  cholera  dejecta. 

1  Grundztige  meiner  Lehren  iiber  Cholera  und  Typhus.    Miiuchen,  1875. 


PARASITIC  THEORIES.  125 


CHAPTER    XIX. 

PARASITIC  THEORIES. 

"We  come  now  to  a  number  of  doctrines  that  may  be  considered  under 
the  common  heading  of  j)arasitic  theories.  They  are  peculiarly  interest- 
ing on  account  of  their  recent  revival,  in  principle  at  least,  by  the  announce- 
ment of  Koch's  views.  It  has  been  thought  advisable  to  devote  a  sejDarate 
chajiter  to  their  consideration. 

Boelim/  in  1838,  described  and  pictured  various  forms  of  cryptogamic 
growth  seen  amid  the  debris  of  cholera  dejecta.  After  death  from  the 
disease  he  found  that  the  bowel  contents  teemed  with  vegetations  of  micro- 
fungi,  and  that  innumerable  round,  oval,  or  elongated  corpuscles  were  to 
be  found  in  all  the  vomits  and  dejections,  as  well  as  in  the  intestinal  canal; 
sometimes  single,  sometimes  two,  three,  four,  or  more,  joined  end  to  end, 
as  links  of  a  chain. 

In  the  microscopical  examinations  of  rice-water  dejections  made  by 
Parkes  in  1848,  he  observed  peculiar  granules  and  corpuscles  which  he 
did  not  at  first  suspect  to  be  of  a  vegetable  or  fungoid  nature.  But  he 
found  large  numbers  of  vibriones.  After  the  appearance  of  the  drawings 
and  descriptions  by  Klob,  Thome  and  Hallier,  Dr.  Parkes  stated  that  his 
granular  bodies  were  identical  with  the  corpuscles  of  those  observers.  He 
said  further  that  he  found  the  same  bodies  in  1819,  in  1854,  and  again 
in  1865,  and  that  they  constituted  the  major  part  of  the  flocculi  of  true 
rice-water  stools. 

The  "annular  bodies"  or  "  cholera-cells "  detected  by  Brittan*  and 
Swayne '  in  the  Bristol  epidemic  of  1849,  and  in  part  confirmed  by  Ben- 
nett of  Edinburgh,  properly  belong  to  the  category  of  alleged  discoveries 
of  cholera-organisms. 

These  cells,  annular  bodies,  or  corpuscles,  are  described  as  follows: 
"  They  vary  very  much  in  size  and  apparent  structure  during  the  different 
stagesof  their  development.  The  smallest  are  of  the  same  size  as,  or 
even  much  less  than,  blood-globules,  so  that  to  show  them  properly  an 
object-glass  of  high  magnifying  power,  such  as  one-eighth,  one-twelfth, 
or  one-sixteenth  of  an  inch,  is  required;  their  walls  refract  light  powerfully; 
fragments  of  them  present  the  appearance  of  small  segments  of  circles. "' 

In  this  connection  mention  must  be  made  of  a  paper  which  Mr.  Fowke 
has  quite  recently  read  before  the  Eoyal  Microscopical  Society,  entitled 
"On  the  First  Discovery  of  the  Comma-bacillus  of  Cholera."*     In  this 

'  Ueber  das  Vorkommen  der  Gahrungskeime  (Pilze)  im  Nahrungskanal  der 
Cholera-Kranken,  quoted  in  J.  Simon's  "Report  to  the  Privj'  Council  for  1866,"' 
p.  518,  and  Die  kranke  Darmschleimhaut  in  der  Asiatischen  Cholera,  etc.  Ber- 
lin, 1838. 

-  London  Medical  Gazette,  1849.  *  London  Lancet,  October  13,  1849. 

4  The  British  Medical  Journal,  March  21,  1885. 


12  Q  ASLITIC  CHOLERA. 

paper  lie  attempts  to  show  b}-  quotations  from  the  writings  of  Drs.  Brittan 
and  Swayne,  as  well  as  by  drawings  reproduced  from  their  original  figures, 
that  those  gentlemen  are  entitled  to  priority  in  the  matter  of  the  discovery 
of  the  cholera-bacillus.     He  Avrites: 

"The  results  of  Dr.  Brittan's  separate  observations  are  veiy  remarkable.  He 
examined  a  sei'ies  of  cases,  from  3  to  20  inclusive,  and  publislied  the  results  in  his 
table  in  the  Medical  Gazette,  for  1849,  vol.  xliv.,  pages  530  to  543.  Dr.  Brittan 
found  some  peculiar  corpuscles  to  be  constant  in  the  intestinal  discharges  of 
cholei-a-patients;  and  similar  bodies,  but  smaller,  though  well  defined,  were  dis- 
covered by  him  in  the  matters  vomited;  they  appeared  larger  and  more  compound 
in  the  dejections;  decreased  as  the  disease  progressed  favorably',  and  vanished 
with  tlie  disappearance  of  the  symptoms.  Dr.  Brittan  afterward  examined, 
under  the  microscope,  specimens  of  healthy  fjBcal  matter,  and  the  fluid  stools  of 
typhus,  typlioid,  and  other  diseases,  but  failed  to  detect  anything  corresponding 
with  the  peculiar  corpuscles  belonging  to  cholera-dejections,  though  he  discovered 
these  bodies  in  cases  of  severe  choleraic  diarrhoea.  From  these  observations,  he 
inferred  that  the  bodies  in  question  were  peculiar  to  cholera,  and  bore  some 
essential  relation  to  the  disease." 

But  interesting  as  " this  page  of  forgotten  history"  undoubtedly  is,  it 
does  not  appear  in  the  least  established,  as  Fowke  maintains,  that  "the 
comma-bacillus  was  known  and  recognized  so  far  back  as  thirty-five  years 
since,  the  discovery  being  made  by  two  Englishmen,  Drs.  Brittan  and 
Swayne."  Fowke  himself  seems  to  feel  this,  for,  says  he,  "  I  am  aware 
that  objections  may  be  taken  as  to  the  exact  shape,  size,  etc. ,  of  the  organ- 
isms figured,  and  the  ordinary  appearance  of  the  comma-bacilli  of  Koch." 
But  it  is  certainly  quite  interesting  to  remember  that  "  peculiar  corpuscles  " 
resembling  Koch's  comma-bacilli  were  long  ago  found  in  the  dejections 
of  cholera  patients,  and  long  ago  supposed  to  bear  some  "  essential  rela- 
tion "  to  the  disease. 

In  the  same  year  {i.  e.  1849)  Dr.  W.  Budd,  of  Bristol,  expressed 
his  belief  that  the  disease  depends  on  a  living  organism,  which  being 
swallowed,  becomes  infinitely  multiplied  within  the  alimentary  canal.  The 
morbid  action  thus  set  up  produces  the  flux  and  other  symptoms  of  cholera. 
This  organism  was  described  as  a  distinct  species  of  fungus. 

Budd  believed  these  fungi  to  be  disseminated  by  contact  with  food, 
but  especially  through  the  drinking  water  of  infected  places. 

Dr.  Lauder  Lindsay, 'in  1854,found  large  bodies, which  from  their  alleged 
resemblance  to  the  gonidia  of  lichens  he  called  gonidic  corpuscles.  He 
described  these  gonidic  bodies  as  globular,  colorless,  nucleated,  and  larger 
than  leucocytes.  Around  the  central  nucleus  a  number  of  spherical 
granules  of  a  bright  greenish-yellow  or  orange  color  were  aggregated. 
He  states  that  he  discovered  them  in  the  stools  of  all  his  cholera-patients. 

In  1856  Dr.  Thomson^  and  Mr.  Eainey  stated  that  they  had  found  in 
the  atmosphere  of  a  ward  filled  with  cholera  patients  particles  distinctly 
having  life,  and  showing  growth  and  movement:  small  flocculent  masses, 
fungi,  bacteria,  and  vibriones;  and  so  abundant  were  these  as  to  cover  some 
of  the  larger  branching  fibers  of  tlie  mycelium. 

Three  German  professors  Hallier,"  Thome,^  and  Klob^  asserted  that  they 

'  Edinburgh  Medical  and  Surgical  Journal,  1854. 

-  On  the  Chemical  Conditions  of  Cholera  Atmospheres.     Lancet,  1856. 

2  Das  Cholera  Contagium.  Botanische  Untei'suchungen  von  Dr.  Ernst  Hallier. 
Leipzig,  1867. 

■»  O.  W.  Thome,  Cylindrotsenium  Cholerse  Asiaticaj,  ein  neuer  in  den  Cholera- 
ausleerungen  gefundener  Pilz.     Virchow's  Archiv.  vol.  38. 

5  Pathologisch-anatomische  Studien  ueber  das  Wesen  des  Cholera-Processes, 
von  Dr.  J.  M.  Klob.     Leipzig,  1867. 


PARASITIC   THEORIES.  ]^27 

had  found  iu  the  dejections  of  cholera  patients  as  well  as  in  the  intestines 
of  those  dead  of  the  disease,,  certain  bodies  of  definite  structure,  belonging 
to  the  class  of  fungi.  They  believed  them  to  contain  the  active  poison  of 
the  disease,  which  gained  admittance  to  the  body  in  drinking  water,  and 
thus  acted  directly  upon  the  intestinal  mucous  membrane.  According 
to  them  these  bodies  were  made  up  of  fine  granules  occupying  a  gelatinous 
substance.  By  subdivision  they  formed  beaded  threads,  which  interlacing 
produced  a  reticulum  within  the  intestinal  mucus.  Hallier  and  Thome 
also  grew  and  cultivated  these  corpuscles  and  ascertained  that  they  devel- 
oped into  larger  spheres,  resembling  cells,  which  again  rapidly  multiplied. 
Bounded  spores,  growing  on  thread-like  fungi,  were  also  described  by  them 
in  connection  with  these  supposed  cholera-corpuscles. 

At  the  International  Cholera  Conference,  which  met  in  18G7  at  Weimar, 
Professor  de  Bary,  the  distinguished  German  botanist,  read  a  statement  in 
reference  to  the  observations  of  Thome,  Klob  and  Hallier.  He  pointed 
out'  that  these  observers  had  failed  to  demonstrate  that  the  fungi  held 
by  them  to  belong  to  cholera  alone,  Avere  sufficiently  well  characterized  to 
enable  one  to  diiferentiate  them  from  similar  organisms  seen  elsewhere. 
Klob,  Thome,  and  Hallier  participated  in  the  conference,  but  appeared 
to  be  unable  to  substantiate  their  claims  regarding  the  specificity  of  the 
organisms  described  by  them. 

Intestinal  fungi,  alleged  to  belong  to  cholera,  were  likewise  described 
by  a  number  of  other  observers,  and  variously  characterized  as  cocci, rods, 
elongated  threads,  chains  of  rods,  beaded  threads,  or  zooglea  masses,  etc. 
Among  these  observers  may  be  mentioned  Colin,"  AVeiger,^  Levis,'  and 
Falger.  ^  Xaturally  enough  the  fungus  theory  found  many  ujiholders. 
But  it  also  met  Avith  very  violent  opposition.  The  opponents  claimed 
that  the  micro-organisms  found  in  greater  or  less  number  in  the  human 
cholera-intestine  were  developed  there  secondarily,  in  consequence  of 
the  changes  caused  by  the  disease.  The  intestinal  mucous  membrane, 
it  was  said,  oif ered  in  this  aSection  a  specially  favorable  soil  for  the  growth 
and  development  of  vegetable  parasites.  Yirchow  and  Hoffmann"  found 
vast  numbers  of  such  fungi  in  the  intestines  of  animals  poisoned  with 
arsenic,  and  other  observers  claimed  to  have  seen  the  same  organisms  in 
many  different  diseases.  So,  too,  Trautmann, '  as  long  ago  as  1869,  claimed 
to  have  shown  that  the  vegetable  parasites  of  cholera,  which  he  called 
decomposition-corpuscles,  were  indistinguishable  from  ordinary  putre- 
factive organisms.  Moreover,  they  were  present  in  healthy  dejections, 
and  contained  no  specific  contagious  principle.  The  gases  of  decomposi- 
tion were,  he  thought,  the  main  agencies  producing  cholera. 

It  is  interesting  to  compare  the  objections  raised  against  these  primitive 
parasitic  theories  with  some  very  similar  objections  made  in  connection 
with  Koch's  recent  doctrine.  Perhaps  it  is  on  this  account,  so  confidently 
asserted  by  the  skeptics,  that  Koch's  teachings,  like  those  of  Hallier  and  the 

'  Verhandking'en  der  Cholera-Conferenz  in  Weimar  am  38  und  39  April,  1867. 
Mtinchen,  1867,  pp.  51-53. 

'^  Beitrage  zur  Biologie  der  Pflanzen. 

3  Ueber  die  Cholerapilze.    Quoted  in  Gaz.  Hebd.,  1868. 

•»  Bericht  iiber  die  Cholei-aausleerungen,  1870. 

=  Der  Ansteckungsprocess  der  Cholera,  1867. 

^  Arsenikvergiftung  und  Cholera,  Archiv.  Mr  Pathol.  Anat.     Berlin.  1870. 

'  Die  Zei-setzimgsgase  als  Ursache  zur  Weitei*verbreitung  der  Cholera.  Von 
Dr.  Trautmann.     Halle,  1869. 


12S  ASIATIC  CHOLERA. 

other  writers  mentioned  above,  represent  but  a  short-lived  phase  in  tlie 
attempted  solution  of  a  problem  that  it  Avould  be  vain  to  pursue  further. 
Such  views  are  as  unscientific  as  possible,  and  if  not  energetically  combat- 
ed would  hopelessly  cripple  all  further  investigation.  Fortunately  they 
are  not  entertained  by  a  majority  of  those  whom  we  most  confidently  rely 
upon  for  active  scientific  work  in  biological  matters.  But  we  cannot 
stop  to  enlarge  on  this  topic  here,  except  in  so  far  as  to  reproduce  the 
often-quoted  views  of  Lewis  and  Cunningham.  As  a  preliminary  it  may  be 
stated  that  the  repeated  assertions  regarding  the  discovery  of  specific  fungi, 
capable  of  communicating  cholera,  finally  led  the  British  Government  to 
select  Drs.  Lewis  and  Cunningham  to  make  a  special  inquiry  into  the 
subject.  This  was  of  course  long  before  Koch's  era.  Li  1868  they  went 
to  India,  and  a  number  of  articles  giving  the  results  of  their  investigations 
appeared  in  the  Bepoiis  of  the  Sanitary  Commissioner  with  the  Govern- 
ment of  India  for  1869  and  1873.  The  conclusions  which  these  English 
investigators  arrived  at  are  embraced  in  the  following  sentences: 

1.  No  "cysts"  exist  in  choleraic  discharges  which  are  not  found  under  other 
conditions. 

2.  Cysts  or  sporangia  of  fungi  are  but  very  rarely  found  under  any  circum- 
stances in  alvine  discharges. 

3.  No  special  f vingus  has  been  developed  in  cholera  stools,  the  fungus  described 
by  Hallier  being  certainly  not  confined  to  sucli  stools. 

4.  The  still  and  active  conditions  of  the  observed  animalcula;  are  not  peculiar 
to  this  disease,  but  may  be  developed  in  nitrogenous  material  even  outside  the 
body. 

5.  The  flakes  and  corpuscles  in  rice-water  stools  do  not  consist  of  epithelium, 
nor  of  its  debris,  but  their  formation  appears  to  dej^end  upon  the  effusion  of  blood- 
plasma;  and  the  "peculiar  bodies"  of  Parkes  found  therewith  correspond  very  close- 
ly in  their  microscopic  and  chemical  characters,  as  well  as  in  the  manifestations  of 
vitality,  to  the  corpuscles  which  are  known  to  form  in  sucli  fluid:  these  are  gen- 
erally to  a  greater  or  less  degree  associated  with  blood  cells,  even  when  the  presence 
of  such  is  not  suspected,  especially  as  the  disease  tends  toward  a  fatal  termination, 
wlien  the  latter  have  been  frequently- seen  to  replace  the  foi'mer  altogether. 

6.  No  sufficient  evidence  exists  for  considering  that  vibriones,  and  such  like 
organisms  prevail  to  a  greater  extent  in  the  discharges  from  persons  affected  with 
cliolera  than  in  the  dischai-ges  of  other  persons,  diseased  or  healthy.  But  that  the 
vibriones,  bacteria  and  monads  (micrococcus)  may  not  be  peculiar  in  their 
nature,  and  may  not  be  tlie  product  of  a  peculiar  combination  of  cii'cumstances,  able 
to  give  origin  to  pecidiar  phenomena  in  i:)redisposed  persons — is  not  proven. 

In  this  connection  the  fact  that  in  our  own  country,  the  late  Dr.  J. 
K.  Mitchell,  writing  more  than  fifty  years  ago  on  the  ''  Cryptogam ic 
Origin  of  Diseases,"  almost  anticipated  our  modern  ''germ  theory,"  deserves 
also  to  be  remembered.' 

The  vibriones  described  by  Pouchct  in  1849,  the  cercomonas  of  Da- 
vaine,  and  the  micro-organisms  discovered  by  Pacini  in  1854,   all  har- 

1  In  a  recent  paper  on  the  ' '  Relations  the  past  Investigations  bear  to  the  modern , " 
Dr.  Sharp,  of  Kansas  City,  after  a  review  of  Koch's  doctrine,  says  (The  Kansas  City 
Medical  Index,  January,  1885): 

"  It  is  ajiparent  that  the  results  of  modern  investigation  are  but  the  logical 
conclusion  of  what  has  gone  before.  After  the  very  first  epidemic  in  this  country 
in  1833-3-4,  Drs.  Mitchell  and  Daniel  Drake  announced  the  hypothesis  that  cholera 
poison  was  a  micro-organism.  And  every  subsequent  epidemic  has  broug'ht  foi'th 
advocates  of  such  an  hypothesis." 

So  that  Drake,  as  well  as  Mitchell,  is  entitled  to  whatever  credit  belongs  to  the 
early  promul.gation  of  a  theory  which  later  researches  have  rendered  an  extremely 
plausible  one. 


THE  RESEARCHES  OF  NEDSWETZKY.  ]^29^ 

monize,  so  far  as  the  parasitic  theory  of  the  disease  is  concerned,  with  the 
modern  doctrine  of  Koch.  And  this  statement  applies  in  a  still  more 
marked  degree  to 

The  Researches  of  Nedswetzky. — For  in  1874  this  writer  positively- 
asserted  that  Asiatic  cholera  was  a  bacterial  disease. '  He  made  numerous  ex- 
periments and  finally  came  to  the  conclusion  that  its  parasitic  origin  could 
not  be  questioned.  According  to  him  various  bacteria  are  always  jjresent 
in  the  fresh  dejections  of  cholera  patients,  in  the  vomited  matter,  urine, 
and  even  in  the  exhaled  breath.  The  blood  likewise  contained  movable 
granules  that  he  supposed  to  be  specific  micro-organisms.  He  also 
made  numerous  culture  experiments  (of  a  very  primitive  kind,  of  course, 
and  without  any  attempt  to  isolate  j)articular  microbes),  which  showed 
nervertheless,  that  the  various  minute  organisms  seen  by  him  were  capable 
of  growth  and  reproduction  outside  of  the  human  body.  The  essential 
parasitic  corpuscles  of  cholera  fluids  were  described  by  Nedswetzky  as  of 
various  kinds.  He  even  mentioned  small  vibrios,  "which  while  moving 
showed  a  kind  of  serpentine  undulation,  and  in  shape  resembled  a  curved 
coimna.^  Yet  it  is  evident  from  Nedswetzky's  own  descriptions  that  these 
comma-shaped  bodies  were  merely  the  vibrios  and  spirilla  ordinarily  seen 
in  putrid  albuminoid  substances,  and  that  they  had  no  ]'elation  to  the 
much  more  minute  comma-bacilli  of  Koch.  It  has  been  thought  advisable 
to  point  out  this  radical  difference  between  Nedswetzky's  commas  and 
those  of  the  German  mycologist,  in  order  to  forestall  the  possibility  of 
priority-claims  such  as  have  been  quite  recently  made  in  behalf  of  Pacini's 
granules.  It  is  nevertheless  strange  that  the  bacteriological  researches  of 
this  author  have  been  so  generally  neglected  by  the  majority  of  recent 
writers,  since  his  ideas  in  many  respects  are  thoroughly  in  unison  with 
those  of  the  present  day,  as  advanced  by  Koch.  It  is  for  this  reason  mainly, 
and  not  on  account  of  their  intrinsic  importance,  that  some  of  the  views 
and  deductions  formulated  by  Nedswetzky  are  here  summarized. 

Among  other  things  he  says  that  four  kinds  of  cholera-bacteria  ( Cholera- 
Bacferidien)  have  been  described: 

1.  A  granular  substance,  found  in  conglomerate  heaps,  and  made  up 
of  the  most  minute  compact  cells  that  remain  motionless.  This  substance 
is  identical  with  the  micrococcus  of  Hallier,  and  the  granular  punctate 
bodies  of  Klob. 

2.  Bacteria  in  the  form  of  chaplets.  They  are  in  motion,  and  resemble 
the  variety  just  described,  but  are  rather  larger.  They  occur  in  pairs  or 
are  found  strung  together  in  chaplet  form. 

3.  Long  bacteria,  composed  of  attenuated  threads,  and  resembling 
ordinary  bacteria. 

4.  The  organisms  of  the  fourth  class  had  been  previously  described 
by  the  author  as  spindle-shaped  bodies.  But  on  careful  examination  they 
were  found  to  be  composed  of  individuals  of  the  third  class  placed  so  closely 
together  as  to  simulate  a  single  organism. 

Nedswetzky  also  foiTud  that  completely  drying  the  cholera  dejections 
destroyed  the  vitality  of  the  cholera-bacteria.  On  the  other  hand,  boiling 
the  fluids  in  which  they  were  contained  did  not  kill  them.  This  last  as- 
sertion may  be  held  to  indicate  the  crudity  of  experiments  of  this  kind 
as  conducted  only  ten  years  ago.  It  is  quite  probable  that  Nedswetzky 
Avas  led  into  erroneously  assuming  the  well-known  Brownian  movements 

1  Zur  Mikrographie  der  Cholera.     Von  Dr.  Eduarcl  Nedswetzky,  Dorpat,  1874. 
^Loc,  citat.,  p.  13. 


130  ASIATIC   CHOLERA. 

of  all  dead  molecular  matter  to  indicate  retained  vitality.  So,  too,  his 
further  experiments  regarding  the  action  of  various  drugs  on  the  viability 
of  his  cholera  bacteria  are  without  value,  and  have  to-day  a  merely  his» 
torical  significance.  The  following  assertions  made  by  the  same  writer 
contain  views  that  will  be  read  with  interest  even  at  the  present  time. 

*'  The  chemica]  agent  producing  fermentation  and  putrefaction  has 
not  hitherto  been  isolated,  because  it  is  a  product  of  the  vital  action  of 
minute  organisms.  For  the  same  reason  the  cholera  poison  has  not  yet 
been  discovered  as  a  separate  substance. 

"  The  cholera-bacteria  are  found  in  such  numbers  in  the  bodies  of 
cholera  patients  that  even  if  we  do  not  assume  them  to  generate  an  infec- 
tious principle,  their  presence  must  still  have  a  prejudicial  effect  upon  the 
health  of  the  sufferer,  or  may  even  lead  to  death." 

The  author  finally  advances  the  folloAving  propositions: 

1.  The  presence  in  the  body  of  such  large  numbers  of  i")arasites  must 
necessarily  excite  some  morbid  action,  as  is  clearly  shown  in  other  par- 
asitic affections. 

2.  In  the  case  of  the  bacteria  in  question  this  morbid  action  is  inva- 
riably identical  with  the  cholera  process,  and  no  otlier  disease  is  caused  by 
them. 

3.  Apart  from  the  presence  of  these  parasites,  no  other  causative 
agencies  are  discoverable  to  account  for  an  attack  of  cholera. 

4.  Whatever  favors  the  development  of  these  bacteria,  also  favors 
cholera.  So  that  we  may  conclude  that  the  causal  relation  between  the 
origin  of  the  one  and  the  appearance  of  the  other,  is  extremely  probable. 
While  as  previously  stated  Nedswetzky's  researches  seem  to  have  been 
forgotten. 

The  Discoveries  of  Pacini  have  led  to  numerous  recent  attempts 
to  vindicate  for  the  illustrious  Italian  priority  over  Koch  in  the  discovery 
of  the  specific  cholera  microbe. 

Before  examining  the  claims  made  in  behalf  of  Pacini  by  several  of  his 
countr\anen,  we  may  briefly  examine  his  own  statements.  This  Avas  a  mat- 
ter of  some  difficulty,  even  quite  recently. 

But  a  short  time  ago  Dr.  Aurelio  Bianchi  caused  to  be  printed  from 
the  original  manuscripts  of  Pacini  a  number  of  observations  never  before 
published. '  So  that  w^e  are  now  able  to  form  an  estimate  of  Pacini's  opin- 
ions from  his  own  Avritings.  These  comprise  notes  of  autopsies  and  of 
microscopical  examinations  of  the  tissues,  and  intestinal  discharges  and 
vomited  matter,  made  in  1855  and  1867.  Pacini  mentions  in  many  places 
the  occurrence  of  erosions  of  the  intestinal  mucous  membrane,  which  he 
attributes  to  the  action  of  specific  micro-organisms,  called  by  him  vibri- 
ones.     He  describes  these  vibriones  in  the  following  language:^ 

"  The  vibriones  which  are  found  in  the  fluids  of  cholera  patients,  seen 
under  a  high  power  of  800  to  1,000  diameters,  resemble  perfectly  a  frag- 
ment of  fibrilla  from  striated  muscular  fiber.  Indeed  every  vibrio  apj^ears 
as  a  series  of  very  minute  globules,  as  a  rule  clearly  visible  with  this 
power.  Sometimes  they  are  less  clearly  seen.  The  smallest  of  these  vib- 
riones are  made  up  of  two  or  three  globules  (those  of  a  single  globule  can 
not  be  distinguished  from  other  molecules  of  the  same  size).     I  have  also 

*  Prof.  Filippo  Pacini,  Nuove  Osservazioni  Microscopiche  sul  Colera.    Memorie 
Inedite,  Raccolte  e  Pubblicate  per  Cura  del  Dottor  Aui*elio  Bianchi.     Milano,  1885. 
•^  Loc.  cit. ,  p.  18. 


THE  DISCOVERIES  OF  PACINI-  231 

seen  them  formed  of  many  more  globules,  even  twelve  or  eighteen.  When 
formed  of  six  or  seven  globules  they  are  not  exactly  straight,  but  a  little 
curved.  Those  of  ten  or  twelve  globules  are  usually  slightly  bent  in  the 
shai^e  of  an  S,  or  in  some  other  shape. 

''  The  vibriones  in  which  the  globules  are  not  very  distinct  are  almost 
perfectly  straight.  Perhaps  the  formation  into  globules  and  the  incurva- 
tion may  be  the  beginning  of  division.  One  of  these  vibriones  made  up 
of  four  globules  was  5mmm.  in  length  and  the  diameter  of  the  globules  was 
a  little  less  than  Immm." 

The  studies  made  in  1855  were  always  upon  fluids  and  tissues  pre- 
viously treated  Avith  corrosive  sublimate,  and  hence  living  micro- 
organisms were  not  described.  This  treatment  was  rendered  necessary 
by  an  order  at  that  time  in  force  which  forbade  the  removal  of  any 
specimens  from  one  room  of  the  hospital  to  the  other,  without  such 
disinfection.  In  1867  Pacini  was  enabled  to  study  the  living  vibriones 
and  described  their  movements.  He  also  at  this  time  made  cultures  of  the 
microbes  by  adding  a  few  drops  of  the  intestinal  fluid  to  an  albuminous 
solution  contained  in  flasks. 

Apart  from  all  controversial  matter,  this  publication  contains  views 
and  statements  that  will  be  read  with  interest. 

In  a  communication  made  to  the  Section  of  Hygiene,  at  the  Interna- 
tional Medical  Congress,  in  Copenhagen,  August  11,  1884,  Professor 
Tommasi-Crudeli  presented  arguments  in  favor  of  upholding  Pacini's  claim 
to  priority  in  this  matter.'  In  1854,  he  stated,  Pacini  described  a  microbe 
clioUiHgene  which  attacked  the  intestinal  mucous  membrane,  and,  multi- 
plying there,  destroyed  its  epithelium.^  This  microbe  (which  was  not 
called  a  bacilkis,  since  nobody  had  then  thought  of  classif^dng  the  schizo- 
mycetes)  was  declared  by  him  to  be  the  cause  of  cholera.  He  found  it 
constantly  in  the  intestinal  mucous  membrane,  and  in  the  dejections  of 
cholera  patients,  during  a  long  series  of  observations  made  by  him  in 
1854-5  and  again  in  1SG5-7.  He  asserted  that  this  microbe  multiplied 
outside  of  the  body  in  excrementitious  matters,  and  called  attention  to 
the  danger  residing  in  linen  soiled  with  choleraic  discharges,  and  also  to 
the  possibility  of  infection  through  drinking  water  containing  the  parasite. 
The  ultra-epidemic  school  of  Florence  rejected  these  ideas  almost  contempt- 
uously, and  in  a  reply  to  their  strictures  made  in  1865,  Pacini  used  these 
almost  prophetic  words:  '"'  When  my  discovery  shall  have  made  the  tour  of 
Europe  and  shall  have  returned  to  Florence  from  without,  it  will  be 
permissible  to  cite  it  in  our  schools;  but  when  that  time  comes  I  shall  be 
no  more."  And,  indeed,  Pacini  died  some  months  before  Koch's  journey 
to  Alexandria.  There  were  some,  however,  who  thought  Pacini's  discov- 
eries worthy  of  serious  consideration,  and  among  them  was  the  author  of 
this  communication.  While  by  no  means  accepting  them  as  conclusive 
of  the  parasitic  nature  of  cholera,  Tommasi-Crudeli  believed  that  the 
presumption  Avas  strong  enough  to  warrant  the  adoption  of  such  measures 
as  wovtld  be  undertaken  were  it  an  established  fact.  Acting  upon  this 
presumption,  during  the  epidemic  at  Palermo  in  1866,  he  established  a 
municipal  laundry  to  which  the  soiled  linen  of  cholera  patients  was  carried 
in  vessels  containing  a  solution  of  chloride  of  lime  or  carbolic  acid.  To 
this  laundry  was  brought  all  the  linen  from  the  public  institutions  and 

'  Archives  Italiennes  de  Biologie.     Vol.  6,  No.  1,  1884. 
*  Lazzetta  Medica  Italiana.     Florence,  1854. 


]^32  ASIATIC  CHOLERA. 

from  a  number  of  private  houses,  but  not  one  of  the  employees  of  the 
establishment  was  attacked  with  cholera.  At  another  laundry,  however, 
located  a  short  distance  from  Palermo,  to  which  soiled  linen  without 
previous  disinfection  was  brought,  several  of  the  laundresses  were  attacked 
with  the  disease  and  died.  The  facts  here  stated  were  reported  at  the 
time  in  a  local  journal. ' 

In  1880  Pacini  competed  for  the  grand  prize  of  the  Academie  des  Lincei 
pour  la  Biologic,  presenting  an  essay  in  whicli  he  recited  again  the  ob- 
servations made  by  him  on  cholera,  as  well  as  his  personal  ideas  in  regard 
to  the  pathological  processes  involved  in  this  infectious  malady.  The 
prize  was  not  awarded  to  him  because  all  the  matter  contained  in  his  essay 
had  appeared  in  publications  prior  to  1878,  thus  not  complying  Avith  the 
conditions  imposed  upon  competitors.  In  justification  of  their  action  in 
this  matter,  the  sub-committee  made  a  report  from  which  the  following  is 
an  extract:  "As  regards  the  nature  of  this  organism  (the  microbe  elude r- 
iegne)  and  its  diffusion  in  the  human  body,  we  know  no  more  now  than 
was  made  known  to  us  by  the  first  observations  of  Pacini  in  1854.  The 
examination  of  the  Avell-preserved  preparations  made  by  Pacini,  proves 
that  the  microbe  is  a  schizomycete  whicli  assumes  the  forms  of  micro-bac- 
teria and  sphero-bacteria;  but  it  has  not  been  shown  by  means  of  cultures, 
and  of  experiments  made  with  the  products  of  these  cultures,  that  this 
organism  differs  essentially  from  the  septic  ferment,  either  in  the  ultimate 
forms  of  its  development  or  in  its  pathogenetic  action.  The  studies  made 
by  Pacini  from  1854  to  18G7  render  it  probable  that  this  parasite  is  repro- 
duced principally  in  the  intestinal  mucous  membrane." 

A  little  later,  in  his  lectures  on  pathological  anatomy  at  Rome  in  1881, 
Tommasi-Crudeli  dwelt  upon  the  discovery  of  Pacini  and  stated  as  his  belief 
that  the  organism  discovered  by  that  observer  not  improbably  bore  a  causal 
relation  to  cholera.  And  he  said  further  that  should  this  presumption 
prove  true,  it  was  not  improbable  that  we  should  in  time  produce  artificially 
a  cholera  vaccine  by  means  of  Avhich  the  human  organism  might  be  pro- 
tected from  grave  choleraic  infection." 

In  a  little  brochure  intended  chiefly  for  popular  instructioii,'  Drs. 
Grassland  Ferrariothus  treat  Pacini's  claims  to  priority  in  this  discovery: 

' '  Forty  3"ears  ago  an  illustrious  Italian  published  a  note  in  which  lie  main- 
tained that  cholera  was  caused  by  a  special  parasite.  The  attempts  to  discover 
tiiis  parasite  were  prolonged,  and  many  approached  the  truth  witliout,  however, 
ever  arriving-  at  it.  We  woidd  mention  here  two  Italians,  Professors  Cadet  and 
Pacini,  to  whom  is  due  the  credit  of  liaving  nearly  simultaneously  asserted  that 
the  seat  of  the  disease  is  in  tlie  intestines,  but  the  parasite  described  by  Cadet  is 
not  found  in  cholera  alone  nor  is  it  tlie  specific  cause  of  the  disease,  and  the  de- 
scription of  Pacini's  microbe  is  not  sufficiently  clear.  .  .  .  Tlie  glory  of  hav- 
ing discovered  tlie  true  and  specific  parasite  of  cholera  belongs  to  Koch." 

"Writing  on  the  same  subject,  Riisconi*  also  does  not  claim  that  Pacini 
actually  discovered  the  comma-bacillus.  But  he  thinks,  that  the  research- 
es of  the  German  savant  "have  given  a  scientific  foundation  to  many  facts 
already  announced  by  Pacini,"  more  particularly  concerning  the  lesions  of 
the  intestine,  due,  as  Pacini  maintained  (though  did  not  prove),  to  the 
presence  of  micro-organisms. 

'  Osservatore  Medico  Siciliano.     Palermo,  1867. 
'•*  Instituzioni  di  Anatomia  Patologica,  vol.  i.,  p.  147,  Rome,  1882. 
2  Per  Difendersi  dal  Colera,  Instituzioni  Popolari,  dei  Dottori  B.  Grassi  and  G. 
Ferrario,  Milano,  1884,  p.  28. 

■*  II  Colera  Asiatico,  Studio  del  Dottor  Ulrico  Rusconi,  Milano,  1885. 


THE  DISCOVERIES   OF  PACINI.  i;:>3 

On  the  other  hand,  D'Urso,  in  a  little  Avork  also  intended  for  po]:»ular 
instruction/  boldly  claims  for  Pacini  and  other  Italian  investigators  the 
honor  of  having  been  the  first  to  assert  that  there  Avere  microbes  in  cholera. 

We  have  given  snfficient  space  to  the  Avritings  of  Pacini,  to  Tommasi 
Crudeli's  argument  in  supjjort  of  the  Italian's  priority  claim,  and  the 
views  of  others,  to  show  that  Pacini  nndonbtedl}^  found  certain  intestinal 
micro-parasites  in  cholera  dejecta  and  in  the  walls  of  the  bowel.  But 
it  is  quite  probable  that  Pacini  did  not  discover  the  true  comma-bacillus. 
Crudeli  apparently  overlooked  the  fact  that  Pacini  described  his  microbes 
as  "of  granular  or  molecular  form,  being  almost  one-thousandth  of  a 
millimetre  in  size. "  ^  Oliveti,  who  quotes  this  description.  ^  also  very  prop- 
erly points  out  that  the  microscopes  in  1854,  when  Pacini  is  said  to  have 
discovered  his  cholera  parasite,  Avere  of  such  poor  construction  compared 
Avith  the  perfect  instruments  of  to-day,  that  it  is  little  Avonder  that  he 
should  not  have  recognized  the  exact  form  of  the  microbe,  and  should  not 
liaA'e  called  it  the  comma-bacillus.  But  since  he  did  not  so  describe  it 
Ave  have  no  certainty  that  he  really  saAV  the  organism  first  accurately  de- 
scribed by  Koch. 

'  Ettore  d'Urso.  Poche  Parole  sul  Colera  disette  ai  Padri  di  Famiolia,  Bari, 
July,  1884. 

-  Filippo  Pacini,  Del  Processo  Morboso  del  Colera  Asiatico.    Fireuze,  1880,  p.  21. 
^  BreA'i  Cenni  sul  Colera  Asiatico.     Napoli,  1884.  p.  6. 


234  ASIATIC  CHOLERA. 


CHAPTEE  XX. 

OTHER  VIEWS  ON  THE  NATURE  OF  CHOLERA. 

Having  given  a  succinct  account  of  the  leading  theories  concerning  the 
etiology  of  cholera,  including  the  parasitic  dotcrines  propounded  before 
Koch's  time,,  we  will  turn  now  to  the  published  opinions  of  several  other 
Avriters.  Among  these  there  are  some  whose  large  experience  with  the 
disease  justly  entitles  them  to  be  heard^  even  if  their  conclusions  cannot 
be  accepted.  The  views  of  a  few  eccentric  authors  will  require  no  further 
refutation  than  their  perusal  will  carry  to  the  mind  of  the  reader.  The 
Avritings  of  Pettenkofer  will  be  critically  reviewed  by  Dr.  Ely  McClellan. 

The  Views  of  Lewis  and  Cunningham. — These  observers  care- 
fully searched  for  characteristic  organisms  in  cholera  and  cultivated  those 
found.  According  to  them,  as  already  stated,  the  bacteria  and  vibrios 
contained'  in  the  stools  present  no  characteristics  by  which  they  can  be 
distinguished  from  those  to  be  seen  in  the  f feces  of  persons  not  suffering 
from  cholera,  or  from  those  occurring  in  putrid  fluids. 

Lewis  and  Cunningham,  however,  believe  in  a  localized  generation  of 
the  disease,  and  point  out  that  they  observed  a  decided  parallelism  between 
cholera  and  malaria.  They  put  the  case  as  follows:  "Does  it  not  seem 
more  reasonable  to  infer  that  the  disease  was  generated  at  or  near  the 
place  of  its  occurrence,  in  the  same  manner  as  outbursts  of  malarious 
fevers  ?  There  is  nothing  more  remarkable  in  the  production  of  an  attack 
of  cholera  than  in  the  production  of  an  attack  of  ague;  in  some  respects, 
indeed,  the  latter  is  the  more  remarkable  of  the  two,  seeing  that,  once 
acquired,  the  symptoms  may  recur  at  long  periods  after  the  original  attack, 
and  Avithout  subsequent  exposure  to  the  influences  that  originally  pro- 
duced it." 

Again  they  say:  "  We  would  not  for  a  moment  have  it  supposed  that 
we  consider  the  two  affections  as  mere  gradations  of  the  same  disease; 
all  that  we  desire  to  urge  is  that  cholera  has  as  good  a  claim  as  malarial 
diseases  to  a  telluric  origin.  What  the  essential  cause  may  be  remains 
unknown  in  both  cases;  but  the  fact  that  the  production  of  malaria  is 
so  generally  under  the  control  of  improvements  in  the  local  conditions 
warrants  us  in  looking  confidently  to  similar  results  with  regard  to  the 
cause  of  cholera  also."  In  this  connection  a  few  words  on  what  may  be 
called 

The  Malarial  Theory  seem  apropos.  This  hypothesis,  like  other 
erroneous  views  regarding  the  origin  of  cholera,  has  many  superficial 
phenomena  in  its  favor.  It  has  always  played  a  great  part  in  the  polemics 
of  cholera,  and  notably  so  in  the  last  great  epidemic  in  the  United  States — 
that  of  1873.     Notwithstanding  many  positive  declarations  that  it  was 


MACNAMARA'S  VIEWS.  ]^35 

true  Asiatic  cholera,  a  most  respectable  if  not  the  largest  number  of  phy- 
sicians, both  numerically  and  intellectually,  while  recognizing  the  disease 
to  have  been  cholera  of  a  fatal  form,  announced  it  as  American  cholera. 
It  was  not  held  to  be  endemic,  but  the  epidemic  was  supposed  to  have  had 
its  origin  in  certain  local  malarial  influences. 

Another  large  class  rejected  entirely  the  cholera  hypothesis,  and  pro- 
nounced the  pestilence  to  have  been  pernicious  bilious  fever  of  an  algid 
t^'pe,  or  a  congestive  malarial  fever,  etc.,  and  when  pressed  by  the  facts 
took  refuge  in  Dr.  Flint's  description  of  these  disorders,  or  behind  such 
terms  as  sporadic  and  septic  cholera.     (Peters. ) 

Dr.  Peters  admits  that  malaria  or  impure  air,  in  all  its  forms, 
not  excluding  swamp  malaria,  may  be  great  allies  in  the  diffusion 
of  cholera;  but  compound  or  mixed  or  civic  bad  air  produced  by  all  the 
causes  which  defile  houses,  grounds,  cities,  towns  and  villages  is,  he  main- 
tains, a  still  more  positive  adjunct. 

Peters  also  writes:' 

"  Drs.  James  Wynne  and  Buckler  fastened  this  pure  malarial  h^-pothesis,  for 
it  does  not  reach  the  dignity  of  a  theory,  in  their  report  of  the  outbreak  in  the 
Baltimore  Almshouse  in  1849,  whicli  was  so  enthusiastically  adopted  by  my  friend 
Dr.  Bell,  of  Louisville,  and  of  which  I  have  said  enough. 

"  During-  our  great  civil  war  the  United  States  had  3,335,943  men  in  the  field, 
not  counting  the  navy  or  the  Confederate  troops;  there  were  1,468,410  cases  of 
malarial  disease,  with  46,310  deaths;  1,765,501  cases  of  intestinal  disease,  with 
44,863  deaths,  and  305  deaths  in  all  from  cholera  morbus;  but  not  one  case  of 
Asiatic  cholera,  because  none  was  imported  from  1861  to  1865,  and  there  was  none 
in  Europe.  In  1866,  when  these  great  armies  wei-e  disbanded,  cholera  was  im- 
ported and  swept  over  the  country. 

"  If  these  blows  are  not  heavy  enough,  study  smy  iiiap  of  the  malarial  districts 
in  Italy,  all  of  which  remained  free  from  cholera,  w'liile  the  non-malarial  districts 
were  attacked  with  it  in  1884.  The  cities  and  provinces  in  Italy  most  heavily 
attacked  by  cholera  last  year  were  Turin,  Cuneo,  Genoa,  Bergamo,  Massa  Car- 
rara, Naples,  Camjiobasso,  etc." 

Macnamara's  Views. — This  English  authority  has  propounded  a 
theory  which  is  a  modification  of  the  one  advanced  by  Snow,  and  also 
shows  a  leaning  toward  the  opinions  expressed  by  Farr  and  Pacini.  Mac- 
namara  asserted  that  the  specific  organic  matter  causing  the  disease  devel- 
oped only  after  the  dejections  had  commenced  to  undergo  decomposition. 
Thus  in  the  fresh  state  the  intestinal  discharges  were  harmless,  but  after 
a  few  days  vibriones  were  formed,  and  then  it  was  that  the  poison  became 
active.  This  dangerous  period  was  of  short  duration,  and  after  standing 
a  few  more  days  the  dejecta  became  again  harmless.  The  matters  passed 
from  the  bowels  might,  however,  be  dried,  and  still  retain  their  potential 
infectious  properties  for  an  indefinite  period,  requiring  only  warmth 
and  moisture  to  become  once  more  active  and  virulent. 

Macnamara  also  stated  that  the  acids  of  the  healthy  stomach,  and  in 
fact  all  acids,  were  capable  of  destroying  the  action  going  on  in  the  cholera 
matter,  and  so  rendering  it  harmless.  Certain  degrees  of  temperature, 
both  high  and  low,  had  a  similar  effect.  Water  was  the  most  common 
medium  by  which  cholera  was  disseminated  among  mankind. 

He  says  further:  ''With  the  exception  of  the  specific  cholera-infect- 
ing matter,  I  entirely  ignore  all  other  causes,  or  combinations  of  causes, 
as  capable  of  producing  this  disease.  The  circumstances  under  which 
people  live  may  predispose  them  to  its  action;  but  neither  aii-,  water,  nor 

'  Manuscript  notes  furnished  to  the  editor. — E.  C.  W. 


X36  ASIATIC  CHOLERA. 

any  other  material  agency  can  induce  an  attack  of  cholera,  though  many 
of  these  may  serve  as  media  by  which  the  infecting  matter  is  conveyed 
into  the  intestines."  Again  in  his  "  History  of  Asiatic  Cholera"  '  he  ex- 
presses himself  as  follows:  ''The  disease  can  likewise  be  propagated  by 
various  articles  of  diet,  such  as  milk,  or  in  fact  by  anything  swallowed 
Avhich  has  been  contaminated  by  the  organic  matter  passed  by  cholera 
patients.  In  badly  ventilated  rooms  the  atmos2)here  may  be  so  fully 
charged  with  the  exhalations  from  the  choleraic  fumes  that  ^^eople  em- 
ployed in  nursing  the  sick  may  become  poisoned. 

"Fluids,  and  probably  solids,  exposed  to  air  of  this  description  absorb 
the  organic  matter,  and  may  thus  become  the  medium  for  transmitting 
the  disease.  In  the  same  way  persons  engaged  in  carrying  the  bodies  of 
those  who  have  died  from  cholera  for  burial,  or  in  washing  their  soiled 
linen,  many  contract  the  malady." 

As  evidence  in  favor  of  the  direct  communicability  of  cholera  by  means 
of  water  contaminated  with  cholera  dejecta,  Macnamara,  among  other 
things,  cites  his  own  experience  in  the  following  case: 

A  small  quantity  of  a  fresh  rice-water  stool  was  accidentally  mixed  with 
some  four  or  five  gallons  of  Avater,  and  the  mixture  exposed  to  the  rays  of 
a  tropical  sun  for  twelve  hours.  Early  the  following  morning  nineteen 
people  each  swallowed  about  an  ounce  of  this  contaminated  water.  They 
only  partook  of  it  once;  but  Avithin  thirty-six  hours  five  of  these  nine- 
,  teen  persons  Avere  seized  Avitli  cholera.  The  choleraic  evacuation  had  not 
touched  the  soil.  As  it  Avas  passed,  so  it  AA'as  SAvalloAved.  But  it  had  been 
very  largely  diluted  Avith  impure  water  and  exposed  to  heat  and  light 
for  tAveh'e  hours. 

Macnamara  describes  in  detail  a  number  of  characteristic  features  of 
Asiatic  cholera  that  are  contained  in  the  folloAving  propositions: 

1.  The  unequal  and  very  partial  distribution  of  cholera  is  the  first 
chai'acteristic  feature  of  the  disease.  This  peculiarity  is  construed  as  a 
poAverful  argument  against  the  acceptance  of  general  epidemic  or  atmos- 
pherical influences  to  explain  the  origin  of  the  disease. 

"This  localized  action  of  cholera,  Avhether  occurring  in  countries, 
towns,  villages,  or  hoAvever  small  the  community  may  be,  is,  in  fact,  a 
characteristic  Avhich  is  more  readily  admitted  than  any  of  its  other 
distinctive  features. " 

Moreover  this  localized  action  must  lead  us  to  assume  "some  more 
tangible  and  specific  cause  than  an  imaginary  something  floating  about 
in  the  air  or  carried  by  the  Avinds  from  place  to  place." 

Macnamara  here  alludes  to  a  Avell-knoAvn  experience,  namely,  that  we 
may  see  "soldiers  in  a  particular  barrack  or  station  struck  doAvn  by  cholera 
while  regiments  on  either  side  of  them  entirely  escape,  precisely  as  though 
the  one  set  of  men  had  been  exposed  to  a  murderous  fire  on  the  battle- 
field, Avhile  the  other  had  been  kept  as  a  reserve  in  camp,  and  out  of 
range  of  the  enemy's  bullets." 

The  history  of  cholera  furnishes  a  multiplicity  of  examples  illustrat- 
ing the  limitation  of  the  disease  to  particular  spots  and  circumscribed 
areas.  As  in  camps,  so  in  toAvns,  one  side  of  a  street  may  be  attacked, 
the  other  completely  escaping.  Even  in  ships  this  singularly  abrupt  ces- 
sation or  limitation  has  been  observed.  One  part  of  a  vessel  may  suffer 
severely;  another  at  the  same  time  not  at  all. 

'  A  History  of  Asiatic  Cholera.     By  C.  Macnamara,  F.  C.  U.     London,  1876. 


MACNA^IAEA'S  VIEWS.  137 

2.  The  inliahitants  of  certain  districts  are  especially  liable  to  he  visited 
hy  cholera,  and  these  localities  hare  features  in  common  with  one  another, 
differing  from  other  2^1  f ices  which  have  nsually  escaped  its  inflnence. 

In  a  general  way  it  has  been  found  that  cholera  has  been  most  de- 
structive in  large  seaport  towns,  and  the  majority  of  these  are  built 
on  low-lying,  alluvial  soils,  at  the  mouths  of  rivers;  frequently  they  are 
densely  populated.  Speaking  broadly,  the  lower  the  level  the  greater  the 
mortality  from  cholera.     There  are  of  course  exceptions  to  this  rule. 

The  prevalence  of  cholera  in  low-lying  towns  was  noticed  by  Jameson 
as  far  back  as  1820.  The  medical  board  of  his  day  explained  the  fact 
by  drawing  attention  to  the  likelihood  of  such  towns  and  places  being 
inhabited  by  an  overcrowded  and  poor  population,  living  under  the  worst 
hygienic  conditions,  breathing  impure  air,  drinking  impure  water,  and 
consuming  impure  food.  Macnamara,  however,  very  properly  points  out 
that  the  disease  has  been  very  virulent  in  places  built  on  high  elevations, 
or  even  on  lofty  mountain  ranges.  He  rightly  believes  that  the  imperfect 
state  of  health  of  the  poor  influences  the  apparent  violence  of  an  out- 
break much  more  than  the  actual  locality  of  their  dwelling-houses.  It 
may  be  borne  in  mind,  however,  that  it  is  precisely  the  lower  classes  who 
commonly  have  their  houses  about  the  lowest  levels  of  a  toAvn.  The  de- 
fective water  supply  of  their  houses  or  huts  may  also  be  noticed  in  this 
connection,  as  favoring  the  susceptibiliy  to  cholera. 

3.  It  hy  no  means,  even  in  the  majority  of  instances,  attacks  tlie  in- 
habitants of  the  most  insalabrious  localities,  even  in  our  larger  towns. 
There  seems  to  be  a  contradiction  between  this  and  the  foregoing  prop- 
osition. But  it  is  apparent  rather  than  real.  Simon  has  demonstrated  that 
while  in  London  many  habitual  seats  of  fever  were  visited  by  the  cholera, 
some  of  the  worst  fever  nests  in  the  whole  metropolis  were  unaffected 
by  it.  But  this  only  proves,  what  hardly  requires  to  be  repeated,  namely 
that  even  under  the  worst  hygieuic  conditonis,  the  disease  cannot  arise 
(le  novo.     This  is  more  clearly  brought  out  in  the  following  statement: 

4.  iVb  amount  of  overcrowding,  no  specicd  condition  of  the  soil,  nor  any 
circnmstance  with  which  we  are  acriuainted,  has  ever  been  known  to  orig- 
inate Asiatic  cholera  de  novo  among  men  removed  from  its  endemic  influence, 
or  iinless  the  disease  has  been  ejndemic  at  the  time  beyond  the  confines  of 
India. 

The  history  of  cholera  teems  with  examples  illustrating  the  truth 
of  this  proposition.  And  especially  we,  the  inhabitants  of  America,  have 
reason  to  believe  implicitly  in  this  highly  important  characteristic  of 
Asiatic  cholera. 

The  crews  of  vessels  among  whom  the  disease  has  apparently  origi- 
nated many  days  out  at  sea,  have  invariably  been  shown  to  nave  had  inter- 
course witii  some  country  affected  with  the  disease. 

5.  The  intensity  of  cJiolera  varies  during  its  continuance  in  a  country 
or  a  large  town,  so  that  it  has  2}eriods  of  little  and  great  activity,  in  fact, 
usually  well-marked  periods  of  increase,  culmination,  and  decline. 

This  characteristic  feature  of  Asiatic  cholera  is  indicated  by  the  fre- 
quent use  of  the  terms  "outburst,"  ''onslaught,"  "outbreak,"  "ravages." 
etc.,  in  connection  with  the  disease,  which  all  denote  the  appalling  rapid- 
ity with  which  a  whole  community  may  be  stricken  down  with  it.  As 
a  rule,  the  first  outbreak  of  cholera  is  the  most  malignant.  The  gradual 
declension  Avliich  follows  may,  however,  be  more  or  less  frequently  inter- 
rupted by  manifestations  of  reneAved  activity  and  virulence  on  the  part  of 


138 


ASIATIC  CHOLERA. 


the  malady.  In  the  Paris  epidemic  of  1831,  of  the  first  98  cases  admitted 
into  a  certain  hospital,  as  many  as  9G  died.  And  similar  instances  of  the 
early  malignancy  of  cholera  abound  in  the  history  of  the  disease  throughout 
all  countries.  A  peculiarity  like  this  can  only  be  rationally  accounted  for 
by  the  action  of  a  specific  organized  cholera-virus. 

6.  After  having  been  a  certain  time  eiJidemic  in  a  locality,  it  entirely 
disappears,  unless  in  if'S  endemic  area. 

Macnamara  observes  that  we  know  no  physical  laws  which  can  ac- 
count for  the  limitation  of  endemic  cholera  to  India,  nor  why  the  disease 
gradually  dies  out  after  a  few  years  of  life  and  vigor  in  any  other  country. 
But  this' in  no  way  detracts  from  the  certainty  or  value  of  the  facts.  Out- 
side of  India,  it  must  always  be  rekindled  by  a  fresh  importation.  Like 
certain  tropical  plants,  it  appears  incapable  of  a  long-continued  existence 
beyond  the  region  from  which  it  originally  sprang;  it  may,  however,  live 
and  bear  fruit  even  in  the  cold  of  a  European  winter,  if  fostered  in  care- 
fully-warmed conservatories,  as,  for  instance,  in  the  overheated  houses  of 
the  Russians.  Unless  cared  for  in  this  way,  it  becomes  dormant  in  the 
cold  of  a  European  winter,  to  sprout  out  again  in  the  heat  of  summer,  but 
with  less  vigor  than  in  the  year  of  its  primary  invasion.  As  regards  this 
remarkable  feature  of  cholera,  it  may  not  be  amiss  to  point  out  here  that 
Koch's  comma-bacilli  are  minute  tropical  plants,  which,  unless  artifi- 
cially cultivated,  show  a  decided  tendency  to  succumb  to  unfavorable 
surroundings.  They  flourish  only  on  suitable  soil;  when  this  is  not  found 
they  are  doomed  to  speedy  death. 

7.  Every  outbreak  of  the  disease  beyond  the  confines  of  British  India  may 
be  traced  back  to  Hindostan,  through  a  continuous  chain  of  human  beings 
affected  with  the  disease,  or  through  articles  stained  with  their  dejecta. 

Cholera  has  never  been  observed  to  travel  faster  than  man  travels. 
In  America  we  can  be  particularly  positive  about  the  truth  contained 
in  this  statement.  For  in  no  single  instance  did  the  disease  break  out 
among  us  before  the  arrival  of  one  or  several  vessels  from  infected  foreign 
ports.  It  never  started  inland,  being  always  first  observed  in  some  sea- 
port town.  For  full  particulars  substantiating  this  assertion  the  reader 
is  referred  to  the  chapters  on  the  history  of  the  disease. 

8.  The  more  explicit  the  examination,  the  clearer  the  fact  appears,  that 
the  disease,  in  the  7naJority  of  cases,  spireads  from  one  human  being  to  an- 
other by  means  of  the  cholera  fomes  finding  its  way  iiito  the  drinking  water, 
and  thus  into  the  intestines  of  other  people. 

So  long  as  Macnamara  admits  that  this  statement  does  not  imply  that 
drinking  water  contaminated  with  choleraic  fomites  is  the  only  and  ex- 
clusive mode  of  dissemination,  we  may  accept  his  opinion  without 
scruple.  The  doctrine  promulgated  by  Snow  in  connection  with  the 
epidemic  of  1849  will  be  seen  to  cover  this  characteristic  feature  of 
cholera. 

Macnamara  further  insists  that,  ''so  surely  as  water  contaminated  with 
choleraic  dejecta  is  capable  of  reproducing  the  disease,  when  consumed 
during  the  vibrionic  stage  of  decomposition,  so  cex'tainly  it  may  be  drunk 
with  impunity  after  this  stage  is  over,  and  when  various  forms  of  ciliated 
infusoria  have  replaced  the  vibriones."  By  which  Macnamara  does  not, 
however,  mean  to  imply  that  the  vibriones  have  any  influence  in  induc- 
ing cholera.  Koch  found  his  comma-bacilli  to  perish  in  the  presence  of 
numerous  bacteria  of  later  development — a  circumstance  that  may  account 
for  the  harmlessness  of  decomposed  dejections. 


THE  VIEWS  ;0F  PETTENKOFEE.  I39 

The  Views  of  Pettenkofer.' — During  the  past  tliirty-five  years  Pet- 
tenkofer  has  given  to  tlie  world  an  extended  array  of  cholera  works.  So 
frequently  and  so  dogmatically  has  he  written  upon  this  disease,  that  it 
would  seem  as  if  he  considered  it  his  own  preemption:  Pettenkofer^s  dis- 
ease. 

This  latter  end  of  the  nineteenth  century  is  unqualifiedly  progressive, 
and  Pettenkofer  is  undoubtedly  the  most  progressive  of  cholera  philoso- 
phers. In  1854  he  adopted  in  an  enthusiastic  manner  the  theory  of  Von 
Gietl  as  to  the  significance  of  diarrhoea  in  cholera,  but  he  soon  found 
that  he  was  untrue  to  himself  in  countenancing  a  too  evident  proposition, 
and  he  thereupon  abandoned  it  for  his  more  elaborate  "  ground-water  "  and 
local  origin  hypothesis.  Upon  this  he  has  erected  a  most  perplexing  super- 
structure, which  he  surrounds  with  a  confused  glamor  of  numberless, 
unmeaning,  and  unnecessarily  tedious  details.  This  he  calls  scientific 
argument. 

At  the  Cholera  Conference  of  1867,  he  remarked:  ''I  have  no  doubt 
whatever  that  cholera  is  propagated  by  means  of  movements  of  men  and 
things,"  but  perceiving  that  for  once  he  had  made  himself  quite  in- 
telligible, he  added: 

"  We  must  start  -with  this  principle,  that  a  given  locality  is  the  focus  of  cholera, 
from  which  tlie  germ  of  the  disease  is  propagated  by  man.  It  is  true,  however, 
that  man,  coming  from  the  infected  locality,  transmits  this  germ;  still  it  is  not  his 
body,  strictly  sj^eaking,  which  is  the  direct  agent  of  transmission.  Recent  experi- 
ences in  Germany,  and  particularly  in  Bavai-ia,  at  Munich,  Heilbronn,  and  Spires, 
do  not  establish  a  correlation  between  tlie  recognition  of  tlie  first  symptoms  of 
cholera  in  a  place  and  tlie  arrival  of  patients  from  an  infected  locality,  so  it  is  still 
the  locality  itself  which  is  the  true  focus  of  the  germ." 

Is  it  any  wonder  that  the  illustrious  Professor  Parkes  arrived  at  the 
conclusion  that  "  Pettenkofer's  views  are  rather  difficult  to  understand," 
and  "that  they  seem  rather  wanting  in  clearness  of  expression.''^ 

The  theory  advanced  by  Pettenkofer  prior  to  1865  was  that  there  was 
necessary  for  the  production  of  cholera — 1.  A  layer  of  soil  permeable  to 
water  and  air,  extending  down  to  the  line  of  the  subsoil  water.  2.  The 
receding  of  the  line  of  the  subsoil  water  from  a  previously  attained  ku- 
nsual  height.  3.  The  presence  of  organic  and  especially  excrementitious 
matter  in  the  receptive  layer  of  soil.  4.  The  specific  cause  of  the  disease 
which  is  carried  chiefly  in  the  intestinal  discharges  of  cholera  patients,  and 
possibly  of  healthy  individuals  also,  who  may  come  from  infected  places. 
5.  An  individual  predisposition  to  the  disease.  He  also  maintained,  6.  That 
the  specific  cause  of  cholera  becomes  active  through  changes  occurring 
in  the  soil,  and  not  within  the  human  organism. 

In  1867,  in  answer  to  Hirsch,  he  said: 

"I  by  no  means  deny  the  transmissibility  of  cholera  by  man  coming  from  an 
infected  place.  I  consider  man  alone  as  the  specific  cause  outside  of  the  influence 
of  the  infected  locality;  moreover,  I  consider  him  the  j^ropagator  of  cholera  when 
he  comes  from  a  place  where  the  germ  of  the  disease  already  exists." 

•  The  writings  of  Pettenkofer  have  been  so  numerous,  and  have  withal  com- 
manded so  much  attention,  that  the  editor  has  deemed  it  permissible  to  allow 
rather  more  space  to  their  consideration  than  their  intrinsic  merit  really  demands. 
Dr.  McClellan  has  kindly  consented  to  give  this  part  of  the  work  his  special  at- 
tention. By  supplementing  the  editor's  material,  as  well  as  by  various  comments 
upon  Pettenkofer's  claims  and  assertions.  Dr.  McClellan  clearly  shows  that  the 
Bavarian  wi-iter's  dogmas  are  quite  untenable. 

*  Army  Med.  Dept.  Reports  of  1873.     London,  1875,  p.  198. 


140  ASIATIC  CHOLERA. 

But  lie  asserted  that  there  must  be  a  local  subsoil  disposition  to  cholera, 
as  evinced  by  the  immunity  enjoyed  by  many  places;  but  there  was  also 
in  places  in  which  the  disease  was  prevalent,  a  varying  rise  and  fall  in  the 
degree  of  local  susceptibility.  The  cause  of  this  variation,  he  asserted,  is 
to  be  found  not  in  the  season  of  the  year  or  in  the  condition  of  the  atmos- 
phere. It  resides  in  the  soil  and  is  due  to  variations  in  the  level  of  the 
subsoil  water,  that  is,  in  the  varying  degree  of  saturation  of  the  ground. 
It  was  still  undetermined,  he  thought,  Avhether  a  certain  condition  of  the 
soil  was  necessary  for  the  development  of  the  cholera  germ,  transmitted  to 
it  through  commerce  or  human  intercourse,  or  Avhether  the  germ  became 
active  independently  of  this  condition,  and  that  an  individual  predisposi- 
tion was  occasioned  by  telluric  influences. 

In  1871  Pettenkofer  again  strenuously  denied  that  cholera  was  a  conta- 
gious or  infectious  disease.  He  insisted  that  the  cause  lay  in  a  local  soil 
disposition.  He  maintained  that  the  spread  of  cholera  in  India  itself  could 
be  explained  much  better  by  his  subsoil-water  theory  than  by  the  atmos- 
pheric theory  of  Bryden.  He  also  claimed  that  by  his  theory  the  immu- 
nity which  certain  places  always  enjoyed,  and  which  others  only  occasionally 
enjoyed,  could  be  satisfactorily  explained.  Again,  having  learned  that 
cholera  epidemics  of  virulent  type  had  occurred  on  ships  in  mid-ocean,  he 
asserted  that  no  one  could  get  cholera  on  shipboard  except  those  individuals 
who  had  imbibed  the  germs  of  the  disease  on  shore,  or  who  had  received 
into  their  system  somesubsoil  water,  or  malaria;  that  there  was  no  spread 
of  the  disease  from  person  to  person  on  shipboard,  no  contamination  of 
fabrics  with  cholera  discharges,  and  that  no  infection  of  food  or  drink 
could  occur;  that  so  soon  as  all  who  had  imbibed  the  disease  on  land 
either  died  or  got  well,  the  ships  were  pure — the  disease  having  died  out, 
as  it  had  no  earth,  soil,  or  siibsoil  water  to  breed  in. 

Pettenkofer  has  evidently  had  but  little  to  do  with  ships — what  a  pity 
he  did  not  know  that  there  was  bilge-water  on  board  ships.  Had  he 
known  that  fact  what  a  magnificent  theory  he  might  have  built  up. 

In  1877  Pettenkofer  was  in  great  danger  of  becoming  finally  intrenched 
in  Bengal.  One  almost  thought  that  he  had  fully  joined  hands  with  the 
Indian  sanitary  commissioners  and  was  at  last  convinced  "that  cholera 
appears  to  be  due  to  certain  conditions  of  air  and  soil,  or  of  both,  as  yet 
little  understood." 

The  Bavarian  savant,  however,  escaped,  for  in  1885  he  is,  if  possible, 
more  emphatic  than  ever  in  support  of  his  local  soil  views,  and  more  viru- 
lent in  defending  them  against  the  adverse  criticism  they  have  so  liber- 
ally received. ' 

The  official  report  as  to  the  variations  of  the  "  ground  water, '^  and  to 
the  general  water  supply  of  the  city  of  Munich  in  1873,  was  most  unfortu- 
nate for  Pettenkof er's  theory. 

"  In  January,  1873,  the  gi'ound  water  was  relatively  deep;  it  rose  in  March,  and 
on  the  30th  of  June  was  higher  than  it  had  been  for  a  long  time.  At  that  time 
the  cholera  commenced;  the  ground  water  fell  a  little  in  July,  but  rose  again  in 
August,  so  that  on  the  ^Tth  of  August  it  stood  at  its  highest  point;  but  while  it 
Avas  tlius  rising  the  cholera  was  at  its  greatest  intensity;  from  the  37th  of  August, 
the  groiuad  water  fell  continuovisly  until  November,  and  during  all  this  time  cholera 
declined,  while,  according  to  Pettenlcofer's  theory,  it  should  have  increased;  on  the 
19th  of  November  the  gi-ound  water  began  to  rise,  and  exactly  at  this  time  cholera 

'  One  critic  went  so  far  as  to  prove  the  introduction  of  cholera  into  the  Bava- 
rian prison  at  Laufen  from  the  verj'  data  fui-nished  to  prove  that  it  had  not  been 
introduced  but  had  originated  from  subsoil  influences. 


THE  VIEWS  OF  PETTENKOFER.  14]^ 

again  increased  and  reached  a  second  acme.  In  January  the  ground  water  fell. 
Cholera  wasjess  than  in  December,  but  still  was  more  than  in  October  and  No- 
vember." Upon  this  evidence  Dr.  Parkes  remarked:  "In  fact,  not  to  go  into  de- 
tails, it  seems  certain  that  no  connection  could  be  maintained  between  the  changes 
in  the  ground  water  and  tlie  cholera  cases,  and  Pettenkofer's  hypothesis  has  thus 
received  a  severe  and  perhaps  fatal  blow  in  the  very  place  where  the  evidence 
was  supposed  to  be  the  most  favorable  to  it." 

His  most  recent  writings  published  originally  in  No7'd  iind  Siid  (then 
reproduced  in  pamphlet  form,'  also  translated  in  full  in  the  London  Lan- 
cet/ and  republished  in  America)/ indicate,  on  comparison  with  his  former 
assertions,  that  he  now  endeavors  to  reconcile  his  local  subsoil  water 
theory  Avith  the  results  of  recent  inquiry  into  the  etiology  of  the  disease. 

Xo  attempt  will  be  made  to  follow  Pettenkofer  through  all  the  wind- 
ings of  this  last  presentation  of  his  theory.  Indeed  space  would  not  be 
taken  for  it  at  all,  were  it  not  that  such  theories  are  mischievous  to  human 
life  and  should  not  pass  unchallenged.  The  component  parts  of  his  theory 
as  it  now  stands  have  been  abstracted  from  his  "  scientific  argument,"  and 
will  be  strung  together. 

Pettenkofer  now  writes: 

"Cholera  is  an  infectious  disease.  By  infectious  diseases  are  meant  those 
diseases  which  are  caused  b}'  the  reception  from  without  of  specific  infective  ma- 
terial into  healthy  bodies,  which  material  acts  like  a  poison.  Infective  material 
difTei*s  essentially  from  lifeless  chemical  poison  in  being-  composed  of  the  smallest 
possible  units  of  living-  matter  which  when  taken  into  healthy  bodies  rapidly  in- 
crease and  multiply  under  certain  conditions  and  by  their  life-growth  disturb  the 
health  of  the  body.  These  germs  of  disease  belong-  to  the  smallest  units  of  life,  to 
the  schizomycetes,  which  lie  on  tlie  bordei'-land  of  the  invisible,  and  which,  ac- 
cording- to  their  form,  are  known  as  cocci,  bacteria,  bacilli,  vibriones,  and  spirilla, 
and  thirty  millions  of  which,  according  to  Naegeli,  hardly  weigh  one  milli- 
gramme! .  .  .  Cholera  always  requires  for  its  propagation  favorable  stations 
on  land,  and,  as  a  rule,  if  the  course  of  epidemics  be  traced,  a  gradual  extension  in 
successive  j'ears  is  found  to  take  place  in  fixed  directions.  .  .  .  Not  only  does 
the  physical  nature  but  also  the  chemical  constitution  of  the  soil  have  an  influ- 
ence on  the  occurrence  of  cholera — to  wit,  the  presence  of  organic  matter  and 
water.  The  influence  of  the  soil  on  the  development  of  infectious  diseases  can 
only  be  understood  by  a  study  of  the  organic  processes  which  take  place  in  it. 
The  processes  are  eventually  dependent  on  the  action  of  the  lowest  organisms, 
which  require  for  their  growth  a  certain  temperature,  so  mucli  water,  air,  and 
food-stuffs.  In  oi'der  to  ex2:)lain  the  occurrence  of  cholera  on  such  varied  soils  as 
those  composed  of  granite,  sand-chalk,  and  shell-chalk,  we  must  suppose  that  the 
soil  contains  in  its  interstices  much  organic  matter  and  water.  .  .  .  The  germs 
of  putrefaction  and  fermentation  abound  in  the  free  atmosphere,  but  they  only 
grow  and  multiply  where  they  find  suitable  food.  The  refuse  from  houses,  dis- 
solved or  suspended  in  water,  forms  an  excellent  nutritive  material  for  the  lowest 
organisms  which  are  so  harmful  to  us.  .  .  It  is  clear,  in  my  opinion,  that  the  soil 
and  the  moisture  of  the  soil  play  a  i^rincipal  part.  The  dampness  of  the  soil  is, 
under  certain  conditions,  clearly  related  to  the  svibsoil- water,  "grundwasser." 
Epidemics  of  cholera  abound  during  the  time  that  the  "grundwasser"  is  falling, 
when  the  earth  is  comparatively  dry.  By  "grundwasser"  is  to  be  understood 
that  condition  of  dampness  of  a  porous  soil  when  all  the  pores  are  filled  with 
water.  K  water  and  air  together  fill  up  the  interstices,  then  the  soil  is  called 
simply  damp.  I  have  so  long  and  so  often  spoken  on  the  influence  of  the  rise  and 
fall  of  the  ground-water  on  the  frequency  of  typhoid  fever  and  cholera,  that  I 
imag-ine  a  great  many  scientists  credit  me  with  the  view  that  subsoil- water  is 
higiily  harmful.  But  such  is  not  tlie  case.  The  subsoil- water  is  merely  an  indi- 
cation of  what  is  going  on,  and  has  no  more  to  do  with  the  actual  processes  than 
a  dial  and  the  hands  have  in  the  going  of  a  clock.     The  fall  of  the  ground-water 

'  Die  Cholera,  von  Max  Von  Pettenkofer.     Berlin  and  Breslau,  1884. 
2  Cholera,  by  Max  Von  Pettenkofer,  Nov.  1,  to  Dec.  20,  1884. 
^Popular  Science  Monthly,  February,  Mai-ch  and  April,  1885. 


142  ASLITIC  CHOLERA. 

by  pumping  away,  or  the  rise  of  ground-water  b^'  the  damming  of  a  stream,  has 
not  the  least  effect  on  typhoid  fever  or  cholera  in  the  neighboiliood.  The  obser- 
vation of  the  level  of  the  surface  of  the  water  in  sjjrings  as  an  indication  of  the 
state  of  the  subsoil- water  is  of  no  value  from  an  etiological  point  of  view,  vinless 
the  spring  be  independent  of  the  nearest  water-course,  and  unless  at  the  time  of 
the  observation  the  real  state  of  the  spring  is  a  true  reflex  of  the  condition  of  the 
subsoil- water  in  its  neighborhood.  .  .  .  When  an  epidemic  of  cholera  occurs 
in  winter,  then  a  relatively  low  state  of  the  ground-water  is  found  to  prevail." 

BiTt  at  ^Iiinicli  in  1873  on  the  19tli  of  Xovember  the  ground  water 
began  to  rise,  and  exactly  at  this  time  cholera  again  increased  and  reached 
a  second  acme. 

It  does  seem  as  if  it  would  be  well  for  Pettenkofer  not  so  persistently 
to  ignore  the  work  of  real  investigators.  One  can  scarcely  believe  that 
he  would  have  Avritten  the  last  sentence  quoted  had  he  been  familiar  Avith 
the  fact  that  a  very  severe  epidemic  of  cholera  occurred  in  Russia  during  the 
winter  of  1853-54  which  could  only  partially  be  accounted  for  by  the  habits 
of  the  Russian  peasants,  the  construction  of  their  houses,  the  faulty  heat- 
ing apparatus  they  employ,  until  Doctor  Routh  pointed  out  that  in  the 
Russian  settlements  everything  is  thrown  out  around  the  dwellings,  and 
that  owing  to  the  intense  cold  and  the  great  expense  of  transporting  drink- 
ing Avater,  the  Russian  peasants  are  in  the  habit  of  drinking  the  water  of 
melted  snow;  that  investigation  shoAved  that  the  snoAv  used  for  that  pur- 
pose was  frequently  that  on  which  cholera  steols  had  been  throAvn,  and 
that  by  this  impure  drinking  Avater  the  epidemic  was  prolonged. 

The  ground  water  during  this  epidemic  Avas  most  certainly  in  "a 
relatively  Ioav  state;"  it  was  most  certainly  in  a  jierfectly  frozen  state,  and 
it  must  he  very  clear,  that  neither  the  soil  nor  its  mixture  played  any  prin- 
cipal part  in  that  epidemic. 

Again  the  peculiar  method  of  reasoning  adopted  by  Pettenkofer  is 
shown  in  connection  with  observations  he  made  in  the  Munich  epidemics 
of  183G,  1854  and  1873,  as  Avell  as  by  certain  alleged  facts  which  he  pre- 
sents regarding  the  city  of  Augsburg  visitation  of  1854.  Because  Munich 
and  Augsburg  are  very  much  alike  in  situation  and  meteorological  factors; 
because  they  are  in  a  direct  line  not  far  apart;  because  differences  in 
amount  of  rainfall  occur;  because  Augsburg  had  an  epidemic  of  cholera 
in  1854  and  none  in  183G  or  1873,  '"when  only  a  few  isolated  cases  occurred;  " 
because  Augsburg  in  place  and  time  and  individual  disposition  is  suscepti- 
ble of  a  cholera  epidemic ;  because  Augsburg  once  lost  three  per  cent,  of 
her  population  from  cholera,  while  Munich  lost  in  the  same  epidemic 
(1854)  but  tAvo  and  a  half  per  cent,  of  her  population;  because  in  1836 
Augsburg  remained  free  from  cholera,  Avhile  ^Munich  was  infested  for  six 
months;  and  because  no  doubt  exists  that  cases  of  cholera  passed,  with- 
out isolation  and  disinfection,  from  Munich  to  Augsburg;  because  of  all 
the  foregoing,  it  is  in'oven  tliat  cholera  is  a  miasmatic  disease  and  may  he 
wholly  independent  of  'human  intercourse. 

The  writer  (Dr.  McClellan)  has  long  been  of  opinion  that  Pettenkofer 
did  not  in  reality  understand  or  comprehend  the  views  of  those  whom  he 
calfe  contagionists. 

Read  what  he  himself  says: 

"I  shaU  now  leave  the  ai-gimients  for  the  locaUsts,  and  pass  on  to  consider  the 
circumstances  which  are  favorable  to  the  Aiews  of  the  contagonists.  That  an  epi- 
demic of  cholera  does  not  permanently  last  in  one  place,  but  after  a  longer  or 
shorter  time  ceases,  is  explained  by  the  contagionists  as  due  to  the  saturation  of 
the  pojnilation,  u-hereby  each  individual  acquires  a  protective  influence  against 
cholera  similar  to  that  acquired  after  vaccination  as  against  small-jJox,  and 


CHAPMAN'S  NEUEOTIC  THEORY.  143 

other  like  instances.  This  hj'pothesis  does  not  explain  whj-  an  epidemic  is  some- 
times rapid  and  sometimes  slow  in  its  coui-se,  why  it  is  sometimes  vast  in  its  rav- 
ages and  at  other  times  slight  in  its  effects,  wliile  the  condition  of  mankind 
remains  practically  the  same.  With  as  much  reason  might  the  localists  assert 
that  the  germs  of  cholera  find  at  different  times  the  local  conditions  to  be  favor- 
able or  unfavorable,  with  the  natural  consequences  of  g•ro^^i:h  or  death." 

The  italics  are  supplied  for  emphasis.  Kot  content  with  forming  a 
theory  for  the  guidance  of  himself  and  followers,  he  manufactures  one  foi' 
those  whom  he  considers  his  opponents  and  whom  he  stigmatizes  as  "  con- 
tagionists."  No  sitch  theory  has  ever  been  advanced  by  any  one  but  Pet- 
tenkofer.  He  really  should  study  up  the  "theory"  (?)  of  well-instructed 
epidemiologists  before  he  writes  again,  when  he  will  find  that  nothing  of 
the  kind  he  has  stated  has  ever  been  claimed;  but,  ere}i  if  he  will  not  do 
so,  if  is  of  no  further  importance. 

Chapman's  Neurotic  Theory  and  Similar  Views. — Dr.  John 
Chapman  is  the  indefatigable  chamj)ion  of  a  rather  ingenious  theory, 
ascribing  cholera  to  a  primary  disturbance  of  the  nerve-centers.  Where 
so  many  distractingly  confusing  theories  have  been  propounded,  we  have 
scarcely  the  right  to  completely  ignore  decided  views,  even  when  they 
seem  on  reflection  irreconcilable  with  fact  and  extravagant.  We  may, 
therefore,  be  permitted  to  briefly  indicate  the  essential  points  in  Chap- 
man's theor}',  as  well  as  the  nature  of  his  pretensions  to  have  it  recognized 
ao  alone  capable  of  explaining  the  true  character  of  cholera. 

Having  repeatedly  claimed  for  this  disease,  and  indeed  all  diarrhoeal 
disorders,  a  purely  neurotic  origin,  Chapman  quite  recently  again  comes 
to  the  front  with  a  loud  floitrish  of  self-assertion.  In  the  Westminster 
Eeview,  for  October,  1884,  he  publishes  an  elaborate  paper  on  '^  The 
Kon-contagiousness,  Causation,  and  Scientific  Treatment  of  Cholera,"'  in 
which  he  substantially  repeats  his  former  yiews  and  adduces  further  al- 
leged evidence  in  support  of  them. 

Chapman  believes  that  his  doctrine  alone  afEords  a  complete  and  con- 
sistent explanation  of  all  the  seemingly  mysterious  phenomena  of  the 
disease.  It  may  be  thus  expressed:  All  the  symptoms  of  cholera  are  due 
to  simultaneous  and  abnormal  superabundance  of  blood  in,  and  excessively 
preternatural  activity  of,  both  the  spinal  cord  and  the  sympathetic 
nervous  centers. 

He  states  that 

"  Dm'ing  the  last  half-century  many  students  of  cholera  have  ascribed  it  to 
disorder  of  the  nervous  system.  In  l'831.  Dr.  G.  H.  Bell,  in  his  work,  'Cholera 
Asphyxia,'  endeavored  to  pi'ove  that  the  disease  is  due  to  a  morbid  state  of  the 
Sympathetic.  Several  other  Anglo-Indian  physicians,  impressed  especially'  by  the 
spasmodic  phenomena  of  tlie  disease,  ascribed  it  to  disorder  of  the  nervous  system. 
In  1833  a  French  pliysician.  Dr.  L.  Auzoux,  published  the  doctrine  '  that  cholera 
is  to  the  great  Sympathetic  what  epilepsy  is  to  the  brain.'  Dr.  Davey,  in  his  work 
on  the  '  Ganglio"^nic  Nervous  System,'  published  in  1858,  claims  to  have  shown 
that  cholera  is  due  to  a  morbid 'state  of  that  system.  The  eminent  English  physi- 
cian. Sir  William  Gull,  refers  the  symptoms  of  the  disease  to  '  an  early  and  severe 
depression  of  the  ganglionic  nervous  centers;'  Dr.  Copland,  in  his  'Medical  Dic- 
tionai-y,'  expresses  a  like  opinion;  and  Dr.  Goodeve,  one  of  the  most  recent  of  the 
Englis'h  authoritative  writers  on  cholera,  says  that  the  state  of  the  huigs  and 
intestines  implies  that  the  nervous  system  is  under  a  morbid  influence.  But 
though  the  authorities  in  favor  of  the  hypothesis  that,  to  a  large  extent  at  least, 
cholera  is  a  disorder  of  the  nervous  system,  are  numerous  and  weiglity,  all  of 
tliem  ascribe  the  disorder  exclusivelv  to  the  action  of  the  Sympathetic:  the  role 
of  the  cerebro-spinal  system  is  wholly  ignored,  and  while  several  of  these  pathol- 
ogists are  of  opinion  that  the  sympathetic  nervovis  system  is  profoundly  depressed 
or  exhausted,  no  one  of  them  explains  in  what  consist  the  several  links  in  the 


144  ASIATIC  CHOLERA. 

chain  of  causation  between  the  alleged  disoi-der  of  this  nei-vous  system  and  the 
manifold  symptoms  of  the  disease." 

He  then  takes  up  seriatim  the  different  symptoms  of  cholera  and  en- 
deavors to  acconnt  for  them  in  the  liglit  his  theory.  This  part  of  his 
argumentation  is  strained,  far-fetched,  and  thoroughly  unsatisfactory. 
He  ignores  the  actual  primary  lesions  of  cholera,  and  substitutes  therefor 
his  suppositious  neurotic  disturbance.  The  various  structural  alterations 
found  in  cholera  are  to  his  mind  merely  secondary  disease-j^rocesses. 

Having  shown  to  his  own  satisfaction  that  all  the  symptoms  of  cholera 
are  produced  by  a  preternatural,  tumultuous  energy  and  activity  of  the 
nervous  system — both  cerebro-spinal  and  sympathetic;  and  that,  though 
extremely  numerous  and  various,  they  are  completely  accounted  for  by 
the  operation  of  one  and  the  same  immediate  cause,  he  disposes  at  one 
stroke  of  all  other  theories,  including  that  of  Koch.     For,  says  he, 

"  While  the  hypothesis  now  briefly  expounded  does  not  exclude  the  possibility 
of  the  existence  of  a  cholei'a  poison,  germ,  or  mici'obo,  it  is  self-sufficing,  and  this 
fact  I'enders  it  extremely  improbable  either  that  any  such  poison,  germ,  or  microbe 
is  causative  of  cholera,  or  that  the  disease  is  in  any  sense  more  infectious  or  con- 
tagious than  is  sunstroke  or  epilepsy." 

Chapman's  treatment  is  by  the  spinal  ice-bag.  He  states  that  it  must 
be  put  exactly  along  the  center  of  the  spine,  and  it  will  do  harm  if  not 
kept  there.  By  this  convenient  doctrine,  he  can  readily  account  for  any 
want  of  success  in  treatment  by  his  method.  Chapman  makes  the  aston- 
ishing claim,  that  his  method  is  approved  alike  by  medical  science  and 
common  sense,  that  it  is  thoroughly  practicable,  that  it  is  sanctioned  by 
the  experience  of  every  physician  who  has  adopted  it,  and  has  been  proved 
to  be  successful  to  a  degree  surpassing  that  of  every  other  kind  of  treat- 
ment which  has  hitherto  been  tried. 

Such  statements  are  certainly  too  much  exaggerated  to  deserve  more 
than  this  passing  mention.  Nor  is  it  surprising  to  find  their  author  en- 
tertaining the  further  equally  false  notion  that  the  summer  diarrhoea  of 
Europe,  the  cholera  infantum  of  the  United  States  of  America,  the  diar- 
rhoea premonitory  of  cholera,  cholera  nostras,  and  Asiatic  cholera  are 
all  mere  varieties  or  grades  of  intensity  of  one  and  the  same  disease,  and 
that  they  are  all  alike  due  to  the  same  proximate  cause,  and  are  controllable 
in  one  and  the  same  way,  namely  by  the  spinal  ice-bag. 

That  associated  with  cholera  there  are  grave  nerve-disturbances  is  dis- 
puted by  no  one.  And  it  would  be  the  part  of  ignorance  to  deny  their 
great  significance  and  importance.  Yet  they  are  secondary  manifesta- 
tions, which  follow  primary  intestinal  disturl)ances  as  clearly  as  do  all  the 
other  symptoms  and  phenomena  that  characterize  an  attack  of  cholera.  It 
is  rendered  probalile  by  the  results  of  recent  investigation  that  chemical 
bodies  allied  to  the  ptomaines  enter  the  circulation,  and  acting  with  great 
energy  upon  the  nerve-structures  produce  those  decided  perturbations  of 
their  functions  witnessed  during  an  attack. 

But  although  we  must  reject  the  theory  of  the  neurotic  origin  of  cholera, 
it  may  nevertheless  be  remembered  that  in  a  somewhat  modified  form,  it 
has  other  supporters  beside  Chapman  and  the  authors  mentioned  by  him. 

Thus  Briquet  and  Mignot,  in  1865,  announced  before  the  Paris 
Academy  of  Medicine  that  cholera  was  due  to  the  action  of  a  miasmatic 
poison  attacking  the  cerebro-spinal  system  and  producing  a  "veritable 
hyposthenization. " 

Again  an  eminent  French  writer,  Laveran,  accepts  almost  unchanged 


NERVE-THEORIES  AND  LEBERT'S  VIEWS.  14 5, 

tlie  views  of  Briquet  and  Mignot.  He  says  that  when  enough  of  the 
cholera  poison  has  found  its  way  into  the  system,  it  attacks  directly  the- 
cerebro-spinal  system,  and  only  through  this  intermediate  nerve-action  the 
cardiac,  pulmonary  and  intestinal  symptoms  are  developed;  even  the  hy- 
peremia of  the  intestinal  mucous  membrane  observed  in  cholera  is,  accord- 
ing to  him,  caused  by  vaso-motor  paralysis. 

In  our  own  country  Dr.  Fred.  Humbert,'  in  a  recent  article  on  Asiatic 
cholera  writes  as  follows:  "  And  now  when  we  collect  all  the  symptoms 
into  one  picture  and  add  our  own  experience  to  form  a  diagnosis,  we  come 
to  the  conclusion  that  we  have  here  a  shock  of  the  nervous  system — promi- 
nently the  sympathetic." 

Another  American  writer.  Dr.  Raymond  Rogers,^  m  an  article  on 
"'Cholera:  Its  disastrous  past  and  its  more  hopeful  future,"  also  maintains 
that  the  disease  is  essentially  a  neurosis.     He  says: 

' '  The  hope  for  better  results  clearly  depends  upon  our  breaking  loose  from  old 
traditions,  old  theories,  old  systems,  so  as  to  be  able  to  read  the  disease  in  the 
pure,  simple  light  of  its  actual  symptoms,  and  its  well-known  cadaveric  autopsies. 
Then  will  the  essential  character  of  the  disease  be  discovered,  and  at  the  same 
time  its  rational  and  successful  treatment." 

Whereupon  he  immediately  "  breaks  loose"  in  the  following  words: 

"It  is  essential  to  the  healthy  physiological  action  of  the  brain,  that  it  be 
supplied  with  currents  of  bJood  normal  in  constitution  and  in  full  measure.  The 
sudden  disturbance  in  its  equilibrium,  in  either  of  these  respects,  is  capable  of  pro- 
ducing sudden  and  sometimes  alarming  or  fatal  effects.  The  pinched  visage, 
sunken  eyeballs,  lusterless  eyes,  burning  thirst,  hoarse  voice,  washerwoman's 
hands,  suppressed  urine,  cold  extremities,  and  the  voiceless  yet  speaking  cadaver, 
all  tell  the  story  of  emptied  blood-vessels  and  a  depleted  brain.  These  conditions, 
necessitate  a  speedy  re-supply  for  the  brain  and  heart.  This  can  be  accomplished 
only  through  the  instrumentality  of  gravitation — hy  2>osition.  Let  it  therefore 
not  be  forgotten  that  the  treatment  of  cholera  resolves  itself,  in  a  measure,  into  a 
simple  problem  in  mechanics — in  hydraulics — upon  the  principle  that  water  (or 
blood)  tends  to  rim  dowai  hill.  This  philosophy  is  emphasized  in  the  fact  that  the 
loss  of  blood  which,  in  the  upright  position,  would  quickly  produce  syncope  or 
death,  would  scarely  be  heeded  in  the  horizontal  position.  Position  thus  becomes 
the  fundamental  consideration  in  the  treatment  of  this  disease — horizontal  in  mild 
cases,  or  inclined,  with  the  head  lowest,  in  grave  attacks.  We  have  reason  to 
suppose  that  position  alone  would  save  a  large  proportion  of  the  cases  which  other- 
wise would  prove  fatal.  In  severe  attacks  tlie  inclination  of  the  body  should  be 
strictly  maintained  until  reaction  becomes  established." 

Comment  upon  this  remarkable  extravaganza  does  not  appear  to  be 
called  for. 

In  striking  contrast  with  these  alarmingly  transcendental  nerve-theo- 
ories  are 

Lebert's  Views. — This  German  writer  of  large  experience  accepts  a. 
cholera  germ  as  the  single  ultimate  cause  of  the  disease.  His  account  of 
the  etiology  of  cholera  is  written,  as  it  were,  with  prophetic  foresight  of 
Koch's  discovery.  He  argues  from  the  facts  belonging  to  the  natural  his- 
tory of  cholera,  and  thus  reaches  conclusions  that  are  in  almost  complete 
harmony  with  the  much  later  views  of  the  German  mycologist.  He  says 
distinctly: 

"In  explaining  the  development  and  diffusion  of  infecting  parasitic  germs,  I 
have  adopted  a  view  which  seems  to  me  not  only  to  be  in  harmony  with  the  facte 
of  natural  history,  but  also  calculated  on  the  one  hand  to  refute  eveiy  exclusive 

'  Journal  of  the  American  Medical  Association,  February  28,  1885. 
nua.,  October,  18,  1884. 


146  ASIATIC  CHOLERA. 

theory,  and  to  show,  on  the  other,  that  we  are  not  jiustified  in  skeptically  reject- 
ing facts  simply  because  they  are  not  constant." 

Lebert  calls  his  theory  the  "mycetic"  one,  for  it  ascribes  the  origin 
and  development  of  cholera  to  parasites  of  the  lowest  form  and  smallest 
size.  He  believes  in  a  minnte,  specific,  and  peculiar  Indian  parasite,  that 
develoj)s  its  action,  wherever  it  is  carried,  provided  it  finds  favorable  con- 
ditions for  prolific  reproduction.  From  what  is  known  of  the  life  of  these 
lowest  organisms,  it  is  readily  understood  that  the  air  cannot  be  the  chief 
agent  in  the  dissemination  oi'  cholera.  When  the  germs  are  fixed  to  some 
lifeless  substance  their  activity  may  be  increased  by  contact  with  fluids. 
The  frequent  infection  of  washerwomen  handling  soiled  linen  is  explained 
by  Lebert  in  this  way. 

The  important  role  played  by  the  water  impregnating  the  soil  is  due  to 
the  fact  that  if  it  be  rich  in  nutritious  matter  for  bacteria,  if  acts  as  a 
breeding-place  for  the  infectious  parasites.  In  drinking  Avater  cholera 
finds  a  frequent  and  potent  medium  of  dissemination,  but  drinking  water 
alone  cannot  be  considered  as  an  exclusive  or  even  necessary  means  of 
conveyance. 

In  other  words,  cholera  recognizes  no  one  element  of  dissemination, 

"not  even  that  most  frequently  injurious,  as  the  sole  sovereign  and  dominant 
factor  in  its  etiology.  Among  the  reasons  why  the  disease  does  not  f ullj-  develop 
under  apparently  favorable  conditions,  we  may  notice  here  again  the  fact  that  the 
germs  maj^  reach  even  an  exvxberant  groA\lh  in  the  water  of  tiie  soil  and  then  be 
destroj'^ed  by  otherwise  innocent  bacteria  of  putrefaction  and  fermentation  before 
tliey  have  come  into  tliorough  contact  with  tlie  human  organism.  A  specific 
germ,  a  favorable  medium  of  development,  sufficient  contact  with  the  huiuan 
organism,  only  slight  and  temporary  development  of  the  protomycetes  destructive 
of  the  cholera  germs,  these  are  the  fundamental  conditions  for  the  development 
and  diffusion  of  cholera  to  any  great  extent,  and  every  perturbation,  every  solu- 
tion of  continuity'  in  the  chain  of  these  factoi-s  of  development  may  prevent  or 
lessen  its  destructive  action. 

"  The  natural  history  of  the  protomycetes  teaches  us  again  that  the  exuberant 
growth  of  the  cholera  germs  may  be  broug-ht  to  an  end,  even  when  at  the  height 
of  their  destructive  acti%ity,  by  the  development  of  other  harmless  parasites." 

It  has  been  shown  that  raftsmen  and  boatmen,  with  their  families,  may 
infect  various  landing  jjlaces.  Dissemination  of  the  disease  on  a  grander 
scale  occurs  in  the  same  way  by  sea  voyages  from  one  part  of  the  earth 
to  another. 

Yet  the  precise  way  in  whicn  the  disease  is  conveyed  may  remain  quite 
obscure  in  particular  instances. 

"  For  the  germs  may  be  disseminated  and  the  disease  spread  by  svibjects  of  chol- 
eraic diarrha?a  who  have  subsequently  recovered  without  further  symptoms,  or 
by  slightly  soiled  linen  and  other  effects  of  cholera  patients.  We  know  how  in- 
visibly and  variousl}^  bacteria  usually  spread  themselves,  and  we  know  that  it  is 
not  possible  for  the  most  carefully  organized  sanitary  police  to  subject  every  chol- 
era germ  to  inspection." 

He  doubts  the  influence  of  dead  bodies  in  communicating  the  disease, 
believing  that  "putrefaction  rather  diminishes  the  capacity  for  infection, 
and  that  the  bacteria  of  decomposition  destroy  the  germs  of  cholera."  It 
will  be  seen  presently  how  completely  these  views  accord  with  Koch's 
doctrine. 

Lebert  believes  that  it  is  possible  for  the  cholera  germs  to  be  dissemi- 
nated by  the  air.     A  strong  proof  of  this  possibility  he  fiiids  in  the  other 
wise  inexplicable 
"occurrence  of  a  pecviliar  diarrhoea  in  large  cities  so  soon  as  cholera  has  taken 


AI^IERICAN  ^^EWS.  147 

root,  as  well  as  that  other  fact  that  during  the  prevalence  of  cholera  diseases  of 
the  most  different  kinds  may  show  some  of  the  unmistakable  signs  of  cholera. 
The  relations  between  cholera  and  other  epidemics  do  not  favor  the  belief  that  the 
one  can  exclude  the  other,  any  more  than  that  they  are  intimately  connected  with 
one  another  as  regards  their  origin." 

But  atmospheric  dissemination  is  insignificant  when  compared  with  the 
far  more  frequent  conveyance  by  infected  water.  He  sums  up  his  yiews 
on  the  subject  in  the  following  manner: 

"  The  truth  is,  nothing  acts  exclusively  in  the  development  of  cholera.  The 
only  indispensable  factor  is  the  cholei-a  germ;  tliis  acts  in  every  case,  from  the 
lightest  to  the  most  severe,  at  every  period,  in  every  epidemic,  in  evei-y  land  of 
the  earth,  and  yet  its  action,  too,  varies  in  extreme  degree.  In  many  cases  it 
causes  but  a  temporar}'  diarrhcea  or  a  light  cholex'ine,  wliile  in  other  cases  it  may 
be  fatal  in  a  few  hours,  the  difference  depending  probably  on  the  numbei-s  in 
which  it  has  entered,  and  on  the  favorable  or  unfavorable  conditions  of  develop- 
ment it  encounters  in  different  individuals.  Since,  then,  all  other  etiological  con- 
ditions must  fii-st  act  through  this  fundamental  cause,  and  since  this  germ  is  dif- 
fused chiefly  by  fluids,  but  may  also  be  spread  by  the  air,  by  the  clothing  and 
bedding-,  by  various  emanations  and  infiltrations,  it  may  be  readilj'  undei-stood 
that  there  is  as  much  irregularity  in  the  nature  of  the  vehicle  of  the  germ  as  in 
the  mode  of  penetration  of  the  veliicle  into  the  recesses  of  the  organism." 

Having  acquainted  the  reader  with  the  etiological  opinions  of  several 
writers,  most  of  whom  are  foreigners,  we  may  now  turn  our  attention  to 
a  few  representative 

American  Views. — The  official  report  on  the  cholera  epidemic  of 
1873  in  the  United  States,'  is  one  of  the  most  instructive  works  on  the  dis- 
ease ever  issued  in  any  country.  Dr.  John  M.  Woodworth  offers  a  series  of 
propositions  "  condensed  from  the  vast  mass  of  cumulative  evidence  which 
has  been  laboriously  collected  by  a  multitude  of  cholera-students  in  both 
hemispheres. "  As  these  propositions  are  intended  to  bear  solely  upon  the 
question  of  the  exclusion  of  the  disease  from  this  country,  they  are  here 
reproduced. 

"1.  ]\Ialignant  cholera  is  caused  by  the  access  of  a  specific  organic  poison  to  the 
alimentary'  canal,  which  poison  is  developed  spontaneously  only  in  certain  parts 
of  India  (Hindostan). 

"  2.  Tliis  poison  is  contained  primarily,  so  far  as  the  world  outside  of  Hindo- 
stan is  concerned,  in  the  ejections — vomit,  stools  and  urine — of  a  person  already 
infected  with  the  disease. 

"3.  To  set  up  anew  the  action  of  the  poison,  a  certain  period  of  incvibation  with 
the  presence  of  alkaline  moisture  is  required,  which  period  is  completed  \\-ithin 
one  to  three  days;  a  temperature  favoring  decomposition  and  moisture  or  fluid  of 
decided  alkaline  reaction  hastening  the  process,  the  reverse  retarding. 

"4.  Favorable  conditions  for  the  gi'owth  of  the  poison  are  found  in  ordinary 
potable  water  containing  nitrog-enous  organic  impurities,  alkaline  carbonates,  etc"; 
in  decomposing  animal  and  vegetable  matter  possessing  an  alkaline  reaction;  in 
the  alkaline  contents  of  the  intestinal  poi'tion  of  the  alimentary  canal. 

"5.  The  period  of  morbific  activity  of  the  poison — wliich  "lasts,  under  favor- 
able conditions,  about  three  daj's  for  a  given  crop — is  characterized  by  the  pres- 
ence of  bacteria,  which  appear  at  the  end  of  the  period  of  incubation  and  disappear 
at  the  end  of  the  period  of  morbific  activity.  That  is  to  saj',  a  cholera  ejection, 
or  material  containing  such,  is  harmless  both  before  tlie  appearance  and  after 
the  disappearance  of  bacteria,  but  is  actively  poisonous  during  their  presence. 

"6.  The  morbific  properties  of  the  poison  maybe  preserved  in  posse  for  an 
indefinite  period  in  cholera  ejections  dried  during  the  period  of  incubation,  or  of 
infection-matter  dried  during  the  period  of  activity. 

' '  7.  The  dried  particles  of  cholera-poison  may  be  caiTied  (in  clothing,  bedding, 
etc.)  to  any  distance;  and  when  liberated  may  find  their  waj-  direct  to  the  almien- 
taiy  canal  through  the  medium  of  tlie  air — by  entering  the  mouth  and  nose  and 

'  Washington,  1875. 


148  ASIATIC   CHOLERA. 

being-  swallowed  with  the  saliva — or,  less  clii'ectly,  through  the  nietlium  of  water 
or  i'ood  in  wliicli  they  have  lodged. 

"8.  The  poison  is  destroyed  natui-ally  either  by  the  process  of  g-rowth  or  by 
contact  with  acids:  (1)  those  contained  in  water  or  soil;  (3)  acid  gases  in  the 
atmosphere;  (3)  the  acid  secretion  of  the  stomach. 

"9.  It  may  also  be  destroyed  ai'tificially  (1)  by  treating  the  cholera-ejections, 
or  matei-ial  containing  them,  with  acids;  (2)  by  such  acid  (gaseous)  treatment  of 
contaminated  atmosphere;  (3)  by  establishing  an  acid  diathesis  of  the  sj'stem  in 
one  who  has  received  the  poison." 

Ill  tlie  same  volume  Dr.  Ely  McClellan  formulates  the  following  propo- 
sitions touching  the  causes  of  epidemic  cholera. 

"1.  Asiatic  cholera  is  an  infectious  disease  resulting  from  an  organic  poison, 
which,  gaining  entrance  into  the  alimentary  canal,  acts  primarily  upon  and  de- 
stroys the  intestinal  epithelium. 

"2.  Tlie  active  agents  in  the  distribution  of  the  cholera  poison  are  the  dejec- 
tions of  pei-sons  suffering  from  the  disease  in  any  of  its  stages.  In  these  dejections 
there  exists  an  organic  matter  which,  at  a  certain  stage  of  decomposition,  is 
capable  of  reproducing  the  disease  in  the  human  organism  to  which  it  has  gained 
access. 

"3.  Cholera  dejecta  coming  in  contact  with  and  drying  upon  any  object,  such 
as  articles  of  clothing,  bedding  and  furniture,  will  retain  indefinitely  their  power 
of  infection.  In  this  manner  a  sure  transmissibility  of  tlie  cholera  infection  is 
eflected,  and  a  distinct  outbreak  of  tiie  disease  may  occur  by  such  means  at  great 
distances  from  the  seat  of  original  infection. 

"4.  The  specific  poison  wliich  produces  the  disease  known  as  cholera  originates 
alone  in  India,  and  by  virtue  of  its  transmissibility  through  the  persons  of  infected 
individuals  or  in  tlie  meshes  of  infected  fabrics,  the  disease  is  carried  into  all 
quarters  of  the  world.  Cholera  has  never  yet  appeared  in  the  western  hemisphere 
until  after  its  route  of  pestilential  march  has  been  commenced  in  the  eastern 
world.  Its  epidemic  appearance  upon  the  North  American  continent  has  in- 
variably been  preceded  by  the  arrival  of  vessels  infected  with  cholera-sick  or 
laden  with  emigrants  and  their  property  from  infected  districts. 

' '  5.  The  respiratory  and  digestive  organs  are  the  avenues  through  which  indi- 
vidual infection  is  accomplished.  Through  the  atmosphere  of  infected  localities, 
cholei-a  is  frequently  communicated  to  individuals.  Water  may  become  contam- 
inated with  the  specific  poison  of  cholera,  from  the  atmosphere,  from  surface- 
washings,  from  neglected  sewers,  cesspools  or  privies.  The  use  of  water  so 
infected  will  induce  an  outbreak  of  the  disease. 

"6.  The  \-iruleiice  of  a  cholera  demonstration,  the  contagion  having  been 
introduced  into  a  community,  is  influenced  by  the  hygienic  condition  of  the  popu- 
lation, and  not  by  any  geological  formation  upon  which  they  may  reside. 

"7.  One  attack  of  cholera  imparts  to  the  individual  no  immunity  fi-om  the 
disease  in  the  future,  but  the  contrary  seems  to  be  established." 

Dr.  Hartshorne  in  1866/  and  again  in  1881/  announced  the  following 

belief: 

"  That  the  cause  of  cholera  is  a  (yet  undiscovei'ed)  protozoon,  or  primal  organ- 
ism, of  extreme  indiAadual  minuteness,  which,  on  entering  the  human  bodj', 
affects  it  as  an  organic  poison.  That  the  varying  quantity  or  number  of  these 
organisms  may  in  different  cases  account  (along  witli  individual  predispositions 
and  exposures)  for  the  unequal  violence  of  different  epidemics,  as  in  the  case  of 
trichiniasis.  Choleraic  diarrhoea  or  cholerine,  so  frequent  before  as  well  as  during- 
and  after  the  prevalence  of  cliolera,  may  in  some  instances,  at  least,  be  explained 
by  the  action  upon  the  alimentary  canal  only  of  a  minimima  quantity  of  the 
cause.  The  dreadful  fatality  of  some  Indian  seasons  is,  on  the  same  view, 
referred  to  an  extreme  accumulation  of  it." 

Dr.  Loomis  ^  considers  epidemic  cholera  an  acute^,  infectious,  non-conta- 

'  Cholera:  Facts  and  Conclusions  as  to  its  Nature,  Prevention  and  Treatment. 
By  Henry  Hartshorne,  A.M.,  M.D.     Philadelphia,  1866. 

-  Essentials  of  the  Principles  and  Practice  of  Medicine.     Philadelphia,  1881. 

3  A  Text-Book  of  Practical  Medicine,  New  York:  W.  Wood  &  Co.,  1884. 
Second  edition,  p.  663. 


AMERICAN  VIEWS.  149 

gious  disease,  probably  of  miasmatic  origin.  As  soon  as  the  cholera  dis- 
charges nndergo  decomposition  the  specific  infection  of  the  disease  is  de- 
Teloped,  and  may  be  conveyed  from  one  locality  to  another  by  the  Avind, 
by  rivers,  and  in  clothing.  An  individual  traveling  rapidly  from  one 
place  to  another  becomes  the  carrier  of  the  germ  whicli  is  to  develop  the 
infection  in  those  localities  in  which  the  conditions  favor  its  reproduction. 
Dr.  Austin  Flint,  sr.,'  in  1881  said: 

"  If  the  germ-theory  be  adopted  as  affording-  the  most  rational  explanation  of 
the  causation  of  other  infectious  diseases,  this  disease  (cholera)  certainly  comes 
within  the  range  of  its  application.  Adopting  this  theory,  the  disease  requires  for 
its  production  a  specific  germ  or  organism.  Adopting-  the  theory  of  indirect  com- 
municabihty,  as  just  stated,  germs  are  contained  in  choleraic  excreta,  but  they 
require  development  under  favorable  conditions  without  the  body  in  order  to  ac- 
quire infective  power.  .  .  .  When  the  cholera-germ  has  undergone  the 
requisite  development,  it  may  be  transported  in  the  atmosphere  or  carried  from 
place  to  place  attached  to  clothing,  merchandise,  etc.  It  is  also  intelligible  that 
undeveloped  germs  may  in  like  manner  be  transported,  and  find,  in  situations 
more  or  less  distant  from  the  places  in  which  they  are  produced,  the  conditions 
favorable  for  their  development." 

More  recently  Flint  is  inclined  to  accept  Koch's  doctrine.'' 
Dr.  Bartholow^  says  that  "the  facts  thus  far  accumulated  render  it 
highly  probable  that  cholera  is  propagated  by  a  minute  organism."     And 
"although  the  cholera  germ  has  not  been  isolated,  the  theory  whicli  as- 
sumes its  existence  best  reconciles  all  the  facts." 

The  most  recent  authoritative  American  writer,  Dr.  Stille,  expresses 
himself  as  follows: 

"  In  looking  now  over  the  field  that  has  been  traversed  in  the  foregoing  pages, 
and  searching  for  some  link  that  will  unite  in  a  consistent  whole  the  causes,  symp- 
toins,  and  lesions  of  cholera,  it  is  evident  that  only  one  factor  can  possibly  be  so 
described.  That  factor  is  the  gastro-intestinal  flux.  This  it  is  that  produces  the 
vomiting  and  the  purging;  that  prostrates  the  patient  and  wastes  awaj^  in  a  few 
hours  the  fullest  and  the  iirmest  form  ;  that  chills  the  limbs  and  afterward  the 
trunk;  that  thickens  the  blood  so  that  the  capillai-y  vessels  can  no  longer  convey 
it,  and  that  spreads  a  cyanotic  shadow  over  the  whole  surface  of  the  body ; 
that  cuts  off  the  supply  of  blood  from  the  lungs  and  heart;  that  paralyzes  the  ner- 
vous system,  ganglionic  as  well  as  cerebro-spinal ;  that  obstructs  the  Iddneys  and 
arrests  their  secretion  ;  and  tliat,  acting  through  the  several  links  of  this  patho- 
logical chain,  becomes  the  cause  of  death.  But  the  question  still  recurs,  What 
is  the  cause  of  the  gastro-intestinal  flux  ?  To  this  also,  in  the  light  of  observation, 
it  is  possible  to  give  only  one  answer.  It  is  a  specific  poison  which  originates  in 
Hindostan,  and,  being  taken  into  the  stomach  and  bowels,  not  only  produces  in  the 
individual  the  symptoms  and  lesions  of  cholera,  but  is  capable  of  multiplying  itself 
and  rendering  infectious  the  discharges  from  the  stomach  and  bowels  of  the  sub- 
jects of  the  disease,  so  that  it  may  be  transmitted  from  one  person  to  another 
round  the  whole  circumference  of  the  globe.  Regarding  the  form  and  natvu-e  of 
that  poison  little  or  nothing  is  definitely  established  beyond  what  has  already 
been  stated  as  the  result  of  Koch's  observations.  As  far  as  they  go,  they  harmo- 
nize with  a  long-prevalent  opinion  that  the  cholera  poison  consists  of  certain 
microscopic  germs,  which,  on  being"  received  into  the  bowels,  propagate  their  kind 
and  destroy  the  epithelium." 

But  against  the  somewhat  exclusive  view  regarding  the  importance 
of  the  gastro-intestinal  transudation,  we  may  cite  those  ^^foudvoyant "  cases 

'  Principles  and  Practice  of  Medicine.     Philadelphia,  1881. 

^  On  the  Parasitic  Doctrine  of  Epidemic  Cliolera.  New  York  Medical  Journal, 
October  25,  1884. 

^  A  Treatise  on  the  Practice  of  Medicine.  By  Roberts  Bartholow,  M.A.,  M.D,, 
LL.D.     New  York,  1881,  p.  731. 


150  ASIATIC  CHOLERA. 

which  kill  without  the  previous  development  of  a  copious  flux.  Evidently 
the  system  can  be  so  overwhelmed  by  virulent  jitomaines  or  other  poisonous 
products,  that  the  "  one  factor"  of  Stille  remains  undeveloped.  But  for 
the  majority  of  cases  Stille's  explanation  is  completely  satisfactory,  and 
indeed  the  only  rational  one  that  can  be  given  in  the  light  of  our  present 
knowledge. 

From  a  study  of  Asiatic  cholera,  more  particularly  as  it  appeared  dur- 
ing the  New  York  epidemic  of  ISGG,  Dr.  Charles  A.  Leale,'  of  that  city, 
concludes  that: 

"  Asiatic  cholera  only  appears  in  America  as  an  epidemic,  which  in  two  or 
three  yeai-s  exhausts  itself.  Its  cause  is  dependent  upon  a  pecuhar  bacilJus  or 
ferment,  which,  when  planted  in  a  suitable  soil,  causes  malignant  cholera.  The 
experience  of  a  veiy  large  propoi'tion  of  the  profession  years  ago  empirically 
demonstrated  that  a  decided  acid  reaction  of  the  secretions  of  the  stomach  and 
bowels  prevented  an  attack. 

Asiatic  cholera  is  a  self-limited  disease,  attacking  all  the  races  of  mankind  and 
at  all  ages:  it  is  of  veiy  short  incubation  and  duration;  it  may  prove  fatal  as  rap- 
idly as  in  three  hoiu-s  from  the  time  of  apparent  health;  it  is  amenable  to  treats 
ment  and  good  nursing." 

The  same  writer  also  relates  a  number  of  events,  personally  witnessed 
by  him,  which  forcibly  illustrate  that  even  under  the  most  favorable  con- 
ditions the  disease  does  not  arise  cle  novo.  Concerning  a  certain  voyage 
across  the  Atlantic  on  board  an  ocean  steamer,  of  which  he  was  the  medical 
officer.  Dr.  Leale  says: 

"Now  surely  here,  in  such  a  reekingly  foul  atmosphei'e,  where  fright  and 
di'ead  wei'e  apparent  on  all  sides,  we  had  many  factors  incorrectly  stated  by  some 
to  be  causes  of  cholera,  but  the  germ  of  cholera  was  not  present;  and,  there- 
fore, althovigh  there  was  a  most  prolific  soil,  yet  not  one  case  of  Asiatic  cholera 
occurred  during  the  entire  voyage." 

1  The  New  York  Medical  Journal,  Jan.  3,  Jan.  24,  and  Feb.  21,  1885 


THE  DOCTRINE  OF  KOCH.  15^ 


CHAPTER  XXI. 

THE  DOCTRINE  OF  KOCH. 

As  the  result  of  a  long  series  of  investigations  into  the  nature  of  cholera, 
undertaken  by  Dr.  Robert  Koch  in  Eg}q3t  during  the  epidemic  of  1883, 
in  India  in  1884,  and  again  in  France  during  the  recent  visitation  of 
1884,  the  German  inquirer  announced  certain  definite  views  concerning 
the  micro -parasitic  nature  of  the  disease. 

The  different  stages  of  progress  made  in  the  investigations  of  the 
German  cholera  commission,  of  which  Koch  was  the  head,  were  commu- 
nicated in  a  series  of  official  reports  to  the  German  government.  But  what 
is  now  universally  known  as  Koch^s  doctrine  was  embodied  in  an  address 
delivered  by  him  at  the  memorable  Berlin  cholera  conference,  held  on  the 
26th  of  July,  1884.  At  this  meeting  many  of  the  leading  German  savants, 
including  authorities  like  Virchow,  Hirsch,  Eulenburg,  Leyden,  von  Berg- 
mann  and  others,  had  assembled  in  order  to  hear  Koch's  statements  and 
to  discuss  the  subject  in  all  its  bearings.  The  address  of  Koch  was  the 
principal  event  of  this  conference,  that  already  may  be  said  to  mark  an 
epoch  in  the  history  of  Asiatic  cholera. 

Koch's  theory  has  indeed  formed  the  starting  and  returning  point  of 
almost  all  the  later  cholera  researches,  down  to  tlie  most  recent  inquiries 
of  the  English  commission. 

IsTo  apology,  therefore,  is  needed  for  here  introducing  this  address' 
almost  completely  in  place  of  merely  giving  a  brief  summary  of  the  German 
author's  views. 

Koch  opened  his  address  by  pointing  out  that — 

for  sanitaiy  measures,  we  require  bases  of  as  firm  a  foundation  as  possible.  It 
is  not  only  a  question  of  very  costly  institutions,  but  of  the  happiness  and  misery 
of  many  people.  This  is  most  especiallj'^  true  for  protection  from  pestilences,  in 
which,  it  can  be  said  without  exaggeration,  the  most  important  sanitary  efforts 
are  being  engaged.  We  should  therefore  suppose  that,  in  the  struggle  against 
pestilences,  people  would  start  from  thoroughly  established  and  scientifically  elab- 
orated facts.  But  unliappily  this  is  not  everywhere  the  case,  and  especially  with 
regard  to  cholera  such  a  firni  basis  is  wanting.  It  is  true  that  a  host  of  views  on 
the  nature  of  cholera,  and  its  mode  of  spreading  and  infection,  have  been  expressed, 
and  vai'ious  theories  have  been  propounded  concerning  it ;  but  the  opinions  are  still 
so  very  divergent,  they  are  so  diametrically  opposed,  that  we  cannot  take  them, 
without  examination,  as  supjiorts  or  starting  points  for  the  measures  we  wish  to 
institute  in  combating  this  plague. 

^  It  was  published  in  the  leading  German  medical  periodicals,  and  has  been 
translated  into  many  foreign  languages.  The  editor  has  used,  with  certain  neces- 
sary modifications  and  corrections,  the  language  of  the  English  translation  which 
appeared  in  the  British  Medical  Journal  of  August  30  and  September  6,  1884. 


X52  ASIATIC  CHOLERA. 

It  is  asserted,  on  the  one  hand,  that  cholera  is  a  specific  disease  originating-  in 
India  ;  on  the  otlier  liand  this  is  disputed,  and  it  is  lield  tliat  cholera  can  also  arise 
spontaneously  in  other  countries,  and  is  not  dependent  on  a  specific  cause.  Some 
hold  that  cholera  is  onlj'  introduced  by  the  cholera-patient  and  his  effects  ;  othei-s 
say  that  it  can  be  spread  by  mercliandise,  by  people  in  good  health,  and  by  cur- 
rents of  air.  Equally  contradictory  opinions  exist  regarding  the  importance  of 
drinking-water  as  a  vehicle  for  conveying  the  infectious  matter,  and  concerning 
the  influence  of  the  conditions  of  the  soil,  as  well  as  in  regard  to  the  question 
wliether  or  not  the  infectious  matter  is  contained  in  the  dejecta  of  the  patient, 
and  finally  on  the  duration  of  incubation.  But  all  these  are  precisely  points  of  the 
greatest  importance  for  the  protection  against  cholera.  And  a  successful  resist- 
ance to  the  disease  will  not  be  possible  till  some  unity  of  opinion  has  been  arrived 
at  on  these  fundamental  questions  of  the  etiology  of  cholera. 

Now  the  etiology  of  this  disease  has  profited  little  fi-om  the  progress  which 
we  have  made  in  the  knowledge  of  the  causation  of  other  infectious  diseases. 
Tliis  progress  has  developed  chiefly  in  the  last  ten  yeai-s;  and  during  that  period 
there  lias  been  no  opportunity'  of  investigating  cholera — at  least  not  in  Europe,  or 
in  adjacent  countries.  But  in  India,  where  the  prevalence  of  cholera  could  have 
continuously  affoi'ded  material  for  investigation,  nobody  has  been  found  to  occupy 
himself  with  this  task  by  applying  the  new  methods  of  investigation. 

In  this  respect  it  was  tlierefore  not  unfavorable  that  cholera  bi-oke  out  last 
year  in  Egj^pt,  and  that  opportunity  was  tlius  given  for  studjing  the  nature  and 
mode  of  infection  of  this  disease  before  it  arrived  on  European  soil.  This  oppor- 
tunity was  utilized  by  various  governments,  which  sent  out  expeditions  to  inves- 
tigate the  nature  of  cholera.  I  had  the  honor  of  superintending  one  of  these 
expeditions. 

Wlien  I  undertook  this  conmiission  I  was  fully  aware  of  the  difficulties  of  the 
task.  Properly  speaking,  nothing  was  as  yet  known  of  the  infectious  matter  of 
cholera.  It  was  not  known  where  to  look  for  it — whtther  it  existed  in  the  intes- 
tinal canal,  or  in  the  blood,  or  elsewhere.  It  was,  further,  not  known  whether 
^ne  had  to  deal  in  this  case  also  with  bacteria,  or  with  fungi  or  something  similar, 
.or  with  animal  parasites — e.  g.,  amuiba.  It  is  true  that,  in  tliis  respect,  there  were 
not  such  important  difficulties  met  wth  as  in  another  direction,  where  I  least  ex- 
pected to  find  them. 

I  had  pictured  to  myself  the  pathological  appearances  constructed  according 
to  the  descriptions  of  the  standard  text-books  ;  and  had  supposed  that  the  intes- 
tine in  cholera  showed  very  few  modifications,  and  that  it  was  filled  with  a.  fluid 
resembling  rice-water.  The  autopsies  that  I  had  previously  seen  I  had  already  half 
ifoi'gotten,  so  that  I  could  not  correct  this  false  idea.  Hence  I  was  at  first  i-ather 
surprised  and  uncertain  when  I  came  to  see  something  else  in  the  intestine.  In  the 
first  autopsies,  it  was  at  once  evident  that,  in  the  majority  of  cases,  extremel.y 
great  and  striking  modifications  were  to  be  found.  Other  cases  again,  showed  only 
slight  changes ;  and,  finally,  I  came  across  cases  which  in  some  degree  corre- 
sponded to  the  type  given  in  the  ordinary  books  of  instruction.  In  spite  of  the 
most  careful  investigation  of  all  the  other  organs  and  of  the  blood,  nothing  was 
to  be  found  which  could  lead  one  to  suppose  that  the  infectious  material  was  to 
be  found  there.  My  attention,  therefore,  was  concentrated  exclusively  on  the 
rnodifications  in  the  intestines, 

Kocli  then  proceeds  to  give  an  account  of  the  appearances  of  cholera 
intestines,  a  description  of  which  Avill  be  found  elsewhere  under  the  head- 
ing of  "  Morbid  Anatomy."     He  then  continues  as  follows: 

When  we  examined  the  intestine  and  its  contents  under  the  mici-oscope,  it 
was  seen  that  in  some  cases,  especially  in  those  in  which  Peyers glands  were  red 
at  the  edge,  an  invasion  of  bacteria  corresponding  to  this  redness  had  taken  place. 
The  diagram  on  next  page  illustrates  this  appearance. 

The  bacteria  had  partly  forced  their  way  into  the  utricular  glands,  partly 
pushed  themselves  between  the  epithelium  and  the  basement-membrane,  thereby 
lifting  the  epithelium  as  it  were.  -In  other  parts,  it  was  seen  that  they  had  forced 
their  way  deeper  into  the  tissue.  Then  cases  were  found  in  which,  behmd  these 
bacteria,  which  had  a  special  appearance  with  regard  to  size  and  shape,  so  that 
one  could  distinguish  them  from  other  bacteria,  and  devote  special  attention  to 
them,  various  other  bacteria  had  forced  tlieir  way  into  the  utricular  glands  and 
the  surroundin'^  tissue,  e.  g.,  large  thick  bacilli  and  very  tloin  bacilli.      Thereby 


THE  DOCTRINE  OF  KOCH.  J  53 

conditions  are  produced  similar  to  those  in  necrotic  diphtheritic  changes  of  the 
mucous  membrane  of  the  intestine,  and  in  typhoid  ulcers,  where  afterward  other 
non-pathogenic  bacteria  force  their  way  into  the  tissue  rendered  necrotic  bj'  path- 
ogenic bacteria.  We  were,  therefore,  from  the  very  beginning,  obliged  to  look 
vipon  these  first-mentioned  bacteria  as  not  altog'ether  unimportant  for  the  cholera- 
process,  while  the  other  changes  gave  the  impression  of  being  secondary  ;  for  the 
bacteria  firet  described  always  advanced  be^'ond  the  others,  they  forced  their  way 
farther  in,  and  gave  the  impression  as  if  they  had  smoothed  the  way  for  the  other 
bacilli. 


a 


Fig.  1. — Section  of  the  mucous  membrane  of  a  cholera-intestine.  A  utricular  g-land  fa')  is  diag- 
onallj- cut  through.  In  its  interior  (hi,  and  between  the  epithelium  and  basement-membrane  (c) 
nmnerous  comma-bacilli.    600  magnifying  power. 

"With  regard  to  the  contents  of  the  intestine,  at  first  no  clear  idea  could  be 
formed,  as  the  only  cases  which  came  before  us  for  exainination  were  not  suitable; 
in  these,  also,  the  contents  of  the  intestine  were  already  putrid  and  bloody.  An 
enormous  quantity  of  various  bacteria  was  found  in  these  contents,  so  that 
there  was  no  possibility  of  attending  to  the  real  cholera-bacilli.  Not  till  I 
had  dissected  a  number  of  acute  and  uncomplicated  cases,  in  which  no  haemor- 
rhage had  as  yet  set  in,  and  in  whicli  the  contents  of  the  intestines  had  not  yet 
undergone  putrid  decomposition,  did  I  recognize  that,  the  purer  and  fresher  the 
cases,  the  more  did  a  special  kind  of  bacteria  prevail  in  the  contents  of  the  intes- 
tines. It  was  soon  clear  that  these  were  the  same  bacteria  which  I  had  seen  in 
the  mucous  membrane.  This  discovery  naturally  turned  my  attention  more  and 
more  to  these  bacteria.  I  investigated  them  in  all  kinds  of  ways,  in  order  to 
establish  their  special  peculiarities.  I  am  able  to  give  the  following  information 
regarding  them. 

These  bacteria,  which  I  have  called  comma-bacilli,  on  accovmt  of  their  pecul- 
iar shape,  are  smaller  than  the  tubercle-bacilli.  The  cholera-bacilli  are  about  half, 
or  at  most  two-thirds,  as  long  as  tubercle-bacilli,  but  much  more  bulky,  thicker, 
and  slighth'  curved.  This  curve  is  generally  not  more  marked  than  that  of  a 
comma;  but  sometimes  it  is  larger,  becoming  semicircular,  as  in  the  adjoining 
figure.  In  other  cases,  it  is  seen  that  the  curve  is  doubled,  that  one  comma  is 
attached  to  another,  but  in  an  opposite  direction,  so  that  it  forms  the  shape  of  an 
S.  I  think  that  in  both  cases  two  individual  ones  after  being  divided  have  re- 
mained stuck  together,  and  accordingly  give  the  appearance  of  a  more  marked  curve 

But  in  the  artificial  cultivations,  beside  these,  another  very  remarkable  form  of 
development  of  the  comma-bacillus  is  to  be  found,  which  is  ver^'  characteristic  of 
it.  The  comma-bacilli  frequently  grow  in  threads  of  longer  or  shorter  length. 
But  they  do  not  then  form  straight  threads,  like  other  bacilli,  for  instance,  anthrax- 


154 


ASIATIC   CHOLERA. 


bacilli,  or,  as  it  appears  in  the  microscopic  picture,  simply  wa\'y  threads,  but  very 
tender  long  spirals,  which,  as  far  as  their  length  and  the  rest  of  their  appearrance 
are  concerned,  bear  the  closest  resemblance  to  the  spirochsetse  of  relapsing  fever 
(see  Fig.  4).     I  could  not  distinguish  one  from  another  if  I  had  them  side  by  side. 


. a 


' c 


^--tt 


Fig.  2. — From  the  contents  of  a  cholera-intestine.  Core  of  necrotic  epithelia  (a).  Semicircular 
comma-bacillus  (b).    Characteristic  grouping  of  bacilli  (c).    600  magnifying  power. 

Fig.  .3. — Object-glass  preparation.  Cholera  dejecta  on  damp  linen  (two  days  old).  At  (o) 
S-shaped  bacilli.    600  magnifying  power. 

Owing  to  this  peculiar  form  of  development,  I  am  also  inclined  to  the  view  that 
the  comma-bacillus  is  not  a  genuine  bacillus,  but  that  it  is,  properly  speaking,  a 
transition  form  between  bacilli  and  spirilla.  Perhaps,  indeed,  we  have  here  to 
deal  with  a  genuine  spirillum,  of  which  we  have  a  fragment  before  us. 


rf. 


Fig.  4.— Object-glass  preparation.  From  the  edge  of  a  drop  of  meat-broth,  with  pure  culture  of 
comma-bacilli.    Long  screw-shaped  threads  (a).    600  magnifying  power. 

Comma-bacilli  can  be  cultivated  in  meaf^broth.  They  grow  in  this  liquid 
very  quickly,  and  in  great  nvxmbers.  This  property  of  theirs  can  be  vitilized  for 
studying  their  other  qualities,  by  examining,  with  a  strong  magnifying  power,  a, 
small  drop  of  meat-broth  cviltivation  on  the  object-glass.  It  is  then  seen  that  the 
comma-bacilli  move  in  a  very  lively  manner.  When  they  are  collected  together 
at  the  edge  of  the  drop,  and  are  moving  about  among  one  another,  they  look 
like  a  swarm  of  dancing  midges,  and  the  long  spiral  threads  appear  also  moving 
in  an  animated  manner,  so  that  the  whole  affords  a  strange  and  extremely  char- 
acteristic pictm-e. 

But  the  comma-bacilli  also  grow  m  other  liquids,  and  especially,  speedily 
and  in  gi'eat  abundance,  in  milk.  They  do  not  make  milk  curdle,  and  do  not 
precipitate  the  casein,  which  many  other  bacteria,  that  can  also  be  raised  in 
milk,  do.  Hence  the  milk  looks  quite  unchanged.  But  if  you  take  a  small  drop 
from  the  surface,  and  examine  it  under  the  microscope,  it  teems  with  comma- 
bacilli.  They  also  grow  in  the  serum  of  blood,  in  which  they  very  quickly  de- 
velop, and  multiply  in  great  numbers.     Again  a  veiy  good  soil  for  the  reproduc- 


ASIATIC  CHOLERA. 


155 


tion  of  comma-bacilli  is  food-gelatine.  This  gelatine  can  serve  for  facilitating 
and  securing  the  discovery  of  comma-bacilli.  For  the  colonies  of  comma-bacilli 
assume,  in  the  g'elatine,  a  most  characteristic  and  definite  form,  which,  so  far  as 
I  can  discern,  and  as  far  as  my  experience  reaches,  no  other  kind  of  bacteria  as- 
sumes in  like  manner. 

The  colony  looks,  when  it  is  very  young,  like  a  very  pale  and  tiny  little  drop, 
which  is,  however,  not  quite  circular  (the  shape  generally  assumed  by  these 
bacteria-colonies  in  gelatine),  but  has  a  more  or  less  irregularly  bordered,  hollowed 
out,  in  parts  also  rough  or  jagged  shape.  It  also  has,  at  a  veiy  early  stage,  rather 
a  granular  appearance,  and  is  not  of  such  regular  character  as  other  colonies  of 
bacteria. 


m 


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Fig.  5. — Colonies  of  comma-bacilli  growing  on  the  gelatine-plate.    Magnified  80  times. 

When  the  colony  becomes  somewhat  larger,  this  gTanvilation  becomes  more 
and  more  evident;  at  last  it  looks  like  a  little  heap  of  strongly  refracting  granules. 
I  might  best  compare  the  appearance  of  such  a  colony  witli  the  appearance  of  a 
little  heap  of  pieces  of  glass.  As  they  grow,  the  gelatine  liquefies  in  the  immedi- 
ate neighborhood  of  the  bacteria  colony,  and  this  latter  at  the  same  time  sinks 
down  deeper  into  the  mass  of  gelatine.  A  funnel-shaped  cavity  is  thus  formed  in 
the  gelatine,  in  the  midst  of  which  the  colony  is  seen  as  a  little  whitish  point. 
This  appearance  is  also  quite  peculiar.  It  is  seen,  at  least  in  this  manner,  in  very 
few  other  kinds  of  bacteria,  and,  as  far  as  I  know,  never  so  mai'ked  as  with  the 
comma-bacilli.     The  sinking  of  the  colonies  can  be  best  observed  when  carrying 


Figs.  6  and  7. 

Fig.  6.— Funnel-shaped  sinking  in  the  gelatine  at  the  inoculation  point  in  the  test-tube. 
Fig.  7. — Natural  size  of  the  colonies  as  they  appear  on  the  gelatine  plate. 

out  an  artificial  cultivation.  A  suitable  colony  is  selected  on  the  gelatine  plate, 
under  a  microscope  with  a  low  power;  it  is  touched  with  a  platinvim  wire, 
previously  heated;  the  bacilli  are  transferred  by  the  wire  into  a  test-tube  with 
gelatine,  and  this  is  closed  with  stei'ilized  wadding.  A  cultivation  of  this  kind 
then  grows  in  the  same  manner  as  tlie  colony  on  the  gelatine-plate.     I  am  in  pos- 


15^  THE  DOCTRINE  OF  KOCH. 

session  of  a  numerous  collection  of  artificial  cultivations  of  bacteria,  made  in  tliis 
manner;  but  I  have  never  seen  in  tlieir  case  sucli  clianges  as  the  comma-bacilli 
cause  after  being-  transferred  into  the  gelatine.  Here,  also,  as  soon  as  the  culti- 
vation begins  to  develop,  you  see  a  little  funnel,  which  marks  the  point  where  the 
inoculation  took  place.  By  degrees,  the  gelatine  liquefies  in  the  neighborhood  of 
this  point  of  inoculation;  then  the  little  colony  is  plainly  seen  extending  itself  more 
and  more.  But  a  deep  spot,  sunken  in,  always  remains,  which  looks  in  the  partially 
liquefied  gelatine,  as  if  an  air-bubble  were  iiovering  over  the  colony  of  bacilli.  It 
almost  gives  the  impression  as  if  the  bacilli- vegetation  not  only  caused  a  liquefac- 
tion of  the  gelatine,  but  also  a  speedy  evaporation  of  the  liquid  formed.  We 
already  know  a  number  of  other  kinds  of  bacteria  which,  in  quite  the  same  man- 
ner, gradually  liquefy  the  gelatine  in  test-tubes,  starting  from  the  point  of  inocu- 
lation. But  in  these  cases  there  is  never  such  a  cavity  nor  this  bubble-like 
hollow  space.  I  must  also  mention  that  the  liquefaction  of  the  gelatine,  starting 
from  a  single  isolated  colony — the  best  way  of  observing  it  in  a  layer  of  gelatine, 
which  is  spread  out  on  the  glass  plate — never  spreads  very|far.  The  dimension  of 
the  liquefied  district  of  a  colony  may  be  estimated  at  one  millimetre.  Other  kinds 
of  bacteria  can  liquefy  the  gelatine  to  a  much  greater  extent,  so  that  a  colony  at- 
tains a  size  of  one  centimetre  in  diameter,  and  more.  In  the  cultivation  of  com- 
ma-bacilli, made  in  test-tubes,  the  liquefaction  of  the  gelatine  extends  by  degrees 
and  very  slowly,  starting  from  the  point  of  inoculation;  and  continues  in  such  a 
manner  that,  after  about  a  week,  the  whole  contents  of  the  tubes  have  become 
liquid.  Unimportant  as  all  these  qualities  seem  in  themselves,  special  weight  is 
to  be  laid  on  them,  because  they  serve  to  distinguish  comma-bacilli  from  other 
kinds  of  bacteria. 

Comma-bacilli  can  also  be  cultivated  on  Ceylon  moss  (Agar-agar),  to  which 
meat-broth  and  pepton  ai-e  added.  This  agar-agar  jelly  is  not  hquefied  by  the 
comma-bacilli.  They  can  also  be  raised  on  boiled  potatoes — a  fact  which  is  very 
important  for  certain  questions.  They  grow  on  potatoes  like  the  bacilli  of 
glanders.  The  latter  form  a  thin,  pulpy,  brownish  coating  on  the  potatoes.  The 
cultivation  of  comma-bacilli,  when  grown  on  potatoes,  look  like  this,  but  not 
colored  so  intensely  brown,  but  rather  light,  grayish  brown. 

Comma-bacilli  flourish  best  at  temperatures  between  86°  and  104°  Fahr.,  but 
they  are  not  very  susceptible  to  lower  temperatures.  Experiments  have  been 
matle  on  this  point,  which  show  that  they  can  grow  very  well  at  62.5°  F.,  though 
more  slowly.  Below  that  point  the  growtli  is  very  small,  and  seems  to  cease 
below  60.8°  F.  In  this  respect  the  comma-bacilli  remarkably  resemble  anthrax- 
bacilU,  which  also  have  this  minimum  temperature  as  the  limit  of  their  growth- 
power.  Once  I  made  an  experiment  to  test  the  influence  of  lower  temperatures 
on  comma-bacilli,  and  to  see  if  they  are,  at  a  very  low  tempei-ature,  not  only 
liindered  in  their  development,  but  also  if  they  cannot  possibly  be  killed.  For 
this  purpose,  an  artificial  cultivation  was  exposed  for  an  hour  to  a  temperature  of 
14°  F. ;  during  this  time  it  was  completely  frozen.  When  part  of  it  was  put  into 
the  gelatine,  there  was  not  the  least  tlilference  visible  in  the  development  or 
growth,  so  that  they  bear  frost  very  well.  It  is  not  the  same  with  the  withdi-awal 
of  air  and  oxygen.  They  immediately  cease  to  grow  when  deprived  of  air,  and 
accordingly  belong,  if  tiie  division  into  aerobic  and  anaerobic  bacteria  be  held  as 
good,  to  the  aerobic  class.  Any  one  can  convince  himself  of  this  very  simplj^  by 
laying  a  piece  of  talc  or  mica  over  the  glass  plate,  when  the  portion  of  the  arti- 
ficial cultivation  has  been  placed  on  it  in  liquid  gelatine,  and  when  the  gelatine 
is  beginning  to  stiffen;  the  talc  or  mica  must  be  as  thin  as  possible,  and  must 
cover  at  least  one-third  of  the  gelatine  surface  in  the  middle.  The  piece  of  mica, 
owing  to  its  elasticity,  adheres  completely  to  the  surface  of  the  gelatine,  and  thus 
cuts  off  the  air  on  the  poi-tion  covered.  Then,  as  soon  as  the  development  of 
the  colonies  follows,  it  is  seen  that  the  development  only  takes  place  where  the 
gelatine  is  not  covered,  and  only  a  trifle,  about  two  millimetres,  under  the  mica- 
plate,  up  to  which  point  the  air  has  been  able  to  force  its  way.  But  under  the 
mica-plate  itself  nothing  grows.  Extremely  small  colonies,  invisible  to  the 
naked  eye,  do,  it  is  true,  appear,  which  probably  owe  their  origin  to  the  oxygen 
existing  in  the  gelatine  but  they  do  not  increase  in  size  afterward.  An  experi- 
ment was  made  in  another  manner.  Little  glasses  containing  food-gelatine,  whicli 
had  been  inoculated  with  comma-bacilli,  were  placed  under  an  air-pump,  and 
others  prepared  in  the  same  manner  were  kept  outside  the  air-pump.  It  was  then 
seen  that  those  under  the  air-pump  did  not  grow,  but  only  those  outside  it.  But 
when  those  tliat  had  been  under  the  air-pump  were  again  placed  in  the  air,  they  be- 


ASIATIC   CHOLERA.  X57 

gaii  to  grow.  Hence  they  had  not  died;  they  only  wanted  the  necessary  oxygen  to 
be  able  to  grow.  The  same  occui-s  when  the  cultivations  are  brought  into  an 
atmosphere  of  carbonic  acid.  While  the  cultivations  that  have  been  kept  for 
comparison  outside  the  carbonic  acid  atmosphere  grow  in  the  usual  manner,  those 
that  are  in  a  stream  of  carbonic  acid  remain  undeveloped.  But  in  this  case,  also, 
they  do  not  die:  for  after  ha\'ing  been  for  sometime  in  the  carbonic  acid,  they 
begin  to  grow  immediately  after  they  have  come  out  of  it. 

On  the  whole,  comma-bacilli,  as  I  have  repeatedly  observed,  grow  veiy 
rapidly.  Their  vegetation  speedily  reaches  a  maximum,  at  which  it  only  remains 
stationary"  for  a  short  time,  then  diminishing  again  very  quickly.  The  comma- 
bacilli,  when  wasting  away,  lose  their  shape;  they  appear  at  one  time  shriveled, 
and  at  another  time  swollen,  and  in  this  state  they  are  not  at  all,  or  only  slightly, 
susceptible  to  color.  The  peculiar  conditions  of  vegetation  of  comma-bacilli  can 
be  best  observ^ed  by  bringing  substances  which  are  rich  in  comma-bacilli,  but  also 
contain  other  bacteria,  e.  g.,  the  contents  of  a  cholera-intestine  or  cholera-dejecta, 
in  contact  with  moist  earth,  or  by  spreading  them  out  on  linen,  and  keeping  them 
in  a  damp  condition.  Comma-bacilli  then  increase  in  a  very  short  time,  e.g.,  in 
an  extraordinary  manner  in  twentj'-four  hours.  Other  bacteria  that  exist  with 
them  are  at  first  stifled  by  the  comma-bacilli,  a  natural  pure  culture  is  formed, 
and,  on  examiumg  with  the  microscope  the  mass  that  is  taken  from  the  surface 
of  the  damp  earth  or  linen,  preparations  can  be  obtained  whicli  show  ahnost  ex- 
clusively comma-bacilli. 

But  this  luxuriant  g-rowth  of  comma-bacilli  does  not  last  long-.  After  two  or 
three  days  they  begin  to  die  off,  and  other  bacteria  then  increase.  The  con- 
ditions become  the  same  as  in  the  intestine  itself.  There  also  a  rapid  multiplica- 
tion takes  place;  but  when  tlie  real  vegetation  period,  which  only  lasts  for  a  short 
time,  is  over,  and  especially  when  exudations  of  blood  into  the  intestine  take 
place,  the  comma-bacilli  disappear,  and  the  other  bacteria,  especially  putrefaction- 
bacteria,  commence  to  develop  in  their  place.  I  am,  therefore,  almost  inclined  to 
believe  that  if  the  comma-bacilli  were  brought  at  first  into  a  putrefied  liquid 
which  contained  a  great  deal  of  the  products  of  vital  changes  of  other  bacteria, 
and  especially  of  puti'efaction-bacteria,  they  would  not  come  to  development,  but 
would  soon  die  off.  But,  so  far,  sufficient  experiments  have  not  been  made  on 
tins  point.  It  is  only  a  supposition  which  I  make,  supported  by  my  experiences 
of  other  bacterical  cultivations.  The  point  is  important,  however.  For  it  is  not 
a  matter  of  indifference  whether  the  comma-bacilli,  if  they  come  into  a  sink,  find 
a  good  or  a  very  bad  soil  for  reproduction.  In  the  first  case,  they  would  multiply 
and  would  have  to  be  destroyed  by  methods  of  disinfection;  but  in  the  latter  case 
they  would  die  off,  and  there  would  be  no  necessity  for  disinfecting.  I  am  in- 
clined to  hold  the  latter  ^^ew,  as  borne  out  by  all  the  experience  I  have  so  far  had. 

The  comma-bacilli  flourish  best  in  hquids  which  do  not  contain  too  small  a 
quantity'  of  nutritive  matters.  Several  experiments  have  been  made  on  this  point. 
Dilutions  of  meat-broth  with  an  alkaline  i-eaction  were  prepared,  and  a  quantity  of 
comma-bacilli  was  placed  in  them.  In  one  of  these  experiments,  the  meat-broth, 
after  a  five-fold  dilution,  proved  to  be  no  longer  a  nutritive  solution.  In  other 
experiments,  the  bacilli  grew  in  a  ten-fold  dilution. 

In  these  cultivation  experiments,  it  was  further  seen  that  the  nutritive  sub- 
stances— at  least,  the  gelatine  and  meat-broth — must  not  be  acid.  As  soon  as  the 
gelatine  shows  onlj^  a  trace  of  acid  reaction,  the  growth  of  the  comma-bacilli  is 
very  stunted.  If  the  reaction  be  in  a  marked  degree  acid,  the  development  of  the 
bacilli  completely  ceases.  It  is  at  the  same  time  noteworthy  that  it  is  not  all  acids 
that  seem  to  act 'unfavorably  on  the  comma-bacillus.  For  the  cut  surface  of  a 
boiled  potato  is  known  to  have  an  acid  reaction.  Nevertheless,  comma-bacilli 
grow  veiy  luxuriantly  on  potatoes.  Hence,  one  cannot  snx,  straight  off',  that  all 
acids  liinder  the  growth;  but,  in  any  case,  tliere  are  a  number  of  acids  winch  have 
this  effect.     In  meat-broth  it  is  probably  lactic  acid,  or  an  acid  phosphate. 

As  the  influence  of  substances  that  prevent  the  development  of  the  growth  of 
comma^bacilli  is  one  of  no  small  interest,  a  number  of  other  substances  have  been 
examined  with  i-egard  to  this  point. 

Iodine  is  known  to  have  been  characterized  by  Davaine  as  a  very  intense 
poison  for  bacteria,  and,  under  certain  circumstances,  correctly  so.  Davaine  made 
his  experiments  by  diluting,  to  a  very  great  extent,  a  liquid  containing  anthrax- 
bacilli,  e.  g.,  anthrax  blood,  until  he  finally  had  nothing  but  pure  water,  in  which 
very  few  anthrax-bacilli  were  suspended.  He  added  iodine  to  this  liquid,  and  then 
it  was  seen  that  the  anthrax-bacilli  were  killed  by  an  extremely  small  quantity  of 


158  THE  DOCTRINE  OF  KOCH. 

iodine;  but  in  practice  the  conditions  are  quite  tlie  reverse.  We  never  have  to 
stop  the  development  of  infectious  matters  in  pure  water,  but  in  tlie  alkahne  con- 
tents of  the  intestines,  or  in  tlie  blood,  or  in  the  juices  of  the  tissues,  and  the 
iodine  does  not  remain  free  in  these,  but  combines  at  once  with  the  alkalies.  The 
investigation  of  the  influence  of  iodine  on  the  comma-bacilli  was  made  by  adding 
iodine-water  to  meat-broth,  which  was  just  suitable  as  a  nutritive  liquid.  Iodine 
dissolves  in  water  in  the  proportion  of  about  1  in  4,000.  One  cubic  centimetre  of 
this  iodine-water  was  mixed  with  ten  cubic  centimetres  of  meat-broth,  but  this 
did  not  hinder  the  g-rowth  of  the  bacilli  in  the  least;  the  limit  at  wliich  iodine 
prevents  the  bacilli  from  developing  must,  therefore,  lie  far  below  the  amount 
used  in  this  expei'iment.  But  it  seems  to  me  unnecessaiy  to  make  any  more  ex- 
periments on  this  point,  as,  in  practice,  larger  quantities  of  iodine  than  tliis  cannot 
be  given. 

Alcohol  stops  the  development  of  comma-bacilli  only  when  one  part  is  added  to 
ten  parts  of  a  nuti-itive  fluid,  i.  e. ,  in  the  proportion  of  ten  per  cent.  This  is  a  con- 
centration which  also  cannot  be  practically  utilized.  Common  salt  was  used  in 
the  proportion  of  3  per  cent,  without  the  growth  of  the  comma-bacilli  being  hin- 
dered. Sulphate  of  iron  only  hinders  the  growth  when  two  per  cent,  is  added  to  the 
nutritive  fluid.  In  regard  to  this  substance,  which  has  been  very  much  used  for  pur- 
poses of  disinfection  in  time  of  cholera,  I  would  state  the  fact  that  a  proportion  of 
two  per  cent,  is  necessary  before  it  acts  as  a  preventive  to  development.  The 
comma-bacilli  are  not  yet  killed  by  the  sulphate  of  ii*on  in  this  concentration. 
The  property  which  sulphate  of  ii'on  has,  of  hindei'mg  the  development  of  tlie 
bacilli,  is,  perhaps,  thus  explained.  The  peptone  and  albuminates  of  the  nutritive 
solution,  which  serve  as  food  for  the  bacteria,  are  driven  out;  for,  by  adding  two 
per  cent,  of  sulphate  of  iron,  an  abundant  precipitate  is  formed  in  the  nutritive 
solution.  Possibly,  also,  the  acid  reaction  that  takes  place  has  a  checking  efi:'ect 
on  the  growth.  Accordingly,  this  substance  seems  not  to  possess  any  specific 
effect  on  the  bacteria,  and  certainly  not  to  be  a  real  material  for  killing  or  disin- 
fection. I  consider  it  indeed  possible  that,  with  such  a  substance,  exactly  the 
opposite  of  what  is  intended  may  be  obtained.  Given  the  case  that  the  contents 
of  a  cesspool  had  to  be  disinfected,  into  which  it  was  known  that  comma-bacilli 
had  found  their  way:  according  to  my  view,  the  process  of  putrefaction  that  goes 
on  of  itself  in  the  cesspool,  is  sufficient  to  kill  the  comma-bacilli.  But  if  sulphate 
of  iron  be  added  till  there  be  an  acid  I'eaction,  and  the  process  of  putrefaction  is 
thei-eby  arrested,  nothing  else  is  obtained  but  cessation  of  the  g-rowth  of  the  bac- 
teria and  of  the  comma-bacilli.  The  bacteria  are  by  no  means  killed  by  this 
method;  and  as  for  the  comma-bacilli,  they  are  removed  from  the  influence  of  the 
putrefaction  bacteria  which  are  injurious  to  them,  and  are  preserved  instead  of 
being  destroyed. 

This  example  is  a  very  good  one  to  show  that  the  substances  for  disinfection 
must  be  correctly  judged  and  examined  precisely  on  this  point,  and  that  we  have 
to  distinguish  between  what  only  arrests  putrefaction  and  what  really  lalls  bac- 
teria. The  former  may  very  possibly  serve  as  a  means  of  preserving  infectious 
matters. 

I  will  only  mention  the  limit  of  the  power  other  substances  possess  of  arrest- 
ing tiie  development  of  comma-bacilli:  Alum,  1  :  100;  camphor,  1  :  300.  I  had 
expected  a  stronger  effect  from  camphor,  but  sevei'al  careful  experiments  have 
shown  that  this  substance  possesses  only  a  very  slight  influence  on  comma-bacilli. 
Cai'bolic  acid,  1  :400.  This  figure  nearly  agrees  with  what  we  know  of  the  influ- 
ence of  carbolic  acid  on  other  bacteria.  Peppermint-oil,  1 : 2,000.  Sulphate  of 
copper,  1  : 2,500.  This  substance  has  a  very  powerful  efl'ect.  But  if  we  want  to 
calculate  how  inuch  sulphate  of  copper  must  be  given  in  order  to  check  the  growth 
of  the  bacilli  in  the  intestinal  canal,  we  should  arrive  at  quantities  which  could 
not  be  given  to  a  hmiian  being.  Quinine,  1  : 5,000;  and  corrosive  sublimate,  which 
IS  here  again  seen  to  exceed  all  other  substances  in  power,  1  :  100,000. 

In  tuese  experiments  on  the  influence  of  substances  for  arresting  the  develop- 
ment of  comma-bacilli,  the  striking-  fact  became  evident  that  comma-bacilli  die 
easily  when  dried.  These  experiments  were  made  by  letting  a  very  small  drop 
of  a  substance  containing  bacilli  dry  on  an  object-glass,  and  a  large  supply  of  these 
object-glasses  was  immediately  prepared  for  a  series  of  experiments.  A  drop  of 
the  liquid  which  was  to  be  examined  was  then  placed  upon  svxch  an  object-glass, 
and  left  for  development  in  the  hollow  object- holder.  Having  proceeded  in  this 
manner,  in  no  single  preparation  did  anj^thing  grow  that  had  received  meat-broth 
as  nutritive  fluid,  nor  in  a  striking  manner  in  the  test-preijarations  either.     At 


ASIATIC  CHOLERA.  159 

first  I  did  not  know  what  caused  the  absence  of  growth,  and  thought  that  the 
broth  must  be  the  cause  of  it.  for  I  liad  never  met  with  anything  hke  this  before 
in  the  case  of  other  bacteria.  For  instance,  anthrax-bacilli  can  be  kept  in  stock 
for  a  long  time  dry  on  object-glasses;  they  retain  vitality  from  half  a  week  to 
nearly  a  whole  week  in  this  manner.  As,  however,  the  meat-broth  on  examina- 
tion proved  to  be  unexceptionable,  we  had  to  examine  whether  the  comma-bacilli 
had  not  probably  died  oft'  owing  to  being  dried  upon  the  object-glass.  In  order  to 
obtain  certainty  on  this  point,  the  following  experiment  was  made:  A  number  of 
object-glasses  were  provided  with  a  small  drop  of  substance  containing  bacilli. 
The  drop  dried  up  in  a  few  minutes.  One  object-glass  was  now  diluted  with  a 
drop  of  nneat-broth  after  an  interval  of  a  quarter  of  an  hour,  another  after  an  in- 
terval of  half  an  hour,  another  after  an  interval  of  an  hour,  and  so  on.  Then  it 
was  seen  (and  I  matle  several  series  of  experiments)  that  the  comma-bacilli  did 
come  to  development  on  the  dried  glass  plates  that  had  laid  a  quarter,  a  half,  and 
a  whole  hour;  but  after  two  hom-s  they  sometimes  died  off;  after  three  hours,  I 
could  not  keep  the  bacilli  alive  in  these  experiments.  Only  when  compact  masses 
of  bacilli  cultivations — for  instance,  when  the  pappy  substance  of  a  cultivation 
made  on  potatoes  was  dried — did  the  bacilli  retain  vitality  for  a  longer  time; 
clearly  because  in  this  case  complete  desiccation  followed  much  later.  But,  also, 
under  these  conditions  I  have  never  succeeded  in  preserving  the  bacilli  alive  in  a 
dried  state  longer  than  twenty-four  hours. 

This  result  was  in  so  far  important,  as  by  its  means  it  could  easily  be  tested 
whether  the  bacteria  have  a  pemianent  state.  We  know  that  other  pathogenic 
bacteria — for  example,  anthrax-bacteria,  which  form  spoi'es — can  be  preserved  for 
years  in  a  dry  state  on  an  object-glass  without  their  dying-.  We  know  also  of 
other  infectious  substances,  with  whose  nature  we  are  not  yet  accurately  ac- 
quainted— for  example,  the  infectious  matters  of  small-pox  and" of  vaccine — which 
can  be  kejit  in  a  dried  state  for  several  yeare,  still  retaining  their  power  of  infec- 
tion. If  now  the  comma-bacilli,  which,  as  such,  are  unexceptionally  speedily 
killed  by  dying,  pass  into  a  lasting  condition  under  some  circumstances,  that 
would  be  very  soon  shown  during  the  process  of  dying. 

This  is  one  of  the  most  important  questions  for  the  etiology  of  an  infectious 
disease,  and  especially  so,  for  cholei-a.  The  investigation  of  this  point  has  there- 
fore been  made  in  the  most  careful  manner  possible.  Above  all,  cholera  dejecta 
and  the  contents  of  the  intestines  of  cholera  corpses  were  left  in  a  damp  condition 
on  linen,  in  order  that  the  comma-bacilli  might  develop  under  the  most  favorable 
circumstances.  After  certain  intervals  of  time,  pieces  of  the  linen  were  dried — for 
example,  after  twenty-four  hours,  after  a  few  days,  after  several  weeks — to  see  if, 
during  this  period,  any  condition  of  permanence  had  been  established.  For  in- 
fection through  cholera  linen  affords  the  onlj'  undisputed  example  of  the  presence 
of  an  effectual  infectious  substance  whicli  adheres  to  a  special  object.  If  there 
were  a  permanent  state  to  be  found  anywhere,  it  must  have  been  found  on  cholera 
linen. 

But  in  none  of  these  cases  was  a  permanent  state  discovered.  When  the 
dried  things  were  examined,  it  was  seen  that  the  comma-bacilli  had  died  off. 
Then,  further,  the  dejecta  were  placed  in  earth,  being  either  mixed  with  earth  or 
spread  on  the  surface,  which  was  either  kept  dry  or  moist;  they  were  mixed  with 
marsh-water,  and  were  also  left  to  decay  without  anything  being  added  to  them. 
In  gelatine-cultivations,  tiie  comma-bacilli  have  been  cultivated  up  to  six  weeks; 
also  in  serum  of  blood,  in  milk,  on  potatoes,  on  which  anthrax-bacilli  are  known 
to  form  spores  extrenielj^  rapidly  and  in  great  abundance.  But  we  have  never 
obtained  a  pei-manent  state  of  comma-bacilli.  As  we  know  that  the  majority  of 
bacilli  have  a  permanent  state,  this  result  must  appear  very  striking.  But  I 
wovild  remind  you,  as  I  mentioned  before,  that  we  nave  most  pi'obably  to  deal 
here  with  a  micro-organism,  which  is  not  a  genuine  bacillus  at  all,  but  is  more 
allied  to  the  gToup  of  screw-shaped  bacteria,  spirilla.  Now  we  do  not  know  of  any 
permanent  state  of  spirilla  as  yet.  Spirilla  are  bacteria  which  depend  for  theiV 
existence  exclusively  on  liquids,  and  do  not,  like  anthrax-bacilli,  vegetate  imder 
certain  conditions  in  which  they  have  for  once  to  endure  a  dry  state.  It  there- 
fore seems  to  me,  as  far  at  least,  as  my  experience  goes,  that  there  is  no  prospect 
of  finding  a  permanent  state  of  comma-bacilli.  I  shall,  later  on,  explain  that  the 
absence  of  a  permanent  state  pei'fectly  coincides  with  the  experiences  of  the  etiol- 
ogy of  cholera. 

If  one  consider  all  the  qualities  of  the  comma-bacilli  that  I  have  hitherto  de- 
scribed, one  must  be  convinced  that  they  belong  to  a  special  well-cliaracterized 


2  (^Q  THE  DOCTRINE  OF  KOCH. 

species  of  bacteria;  and  that  by  means  of  their  characteristic  qualities  they  can 
easily  be  recognized  and  disting-uished  from  other  bacteria. 

After  obtaining-  this  conviction,  it  was  above  all  important  to  establish  the 
relations  between  the  comma-bacilU  and  the  real  process  of  cholera;  and,  first.  I 
had  to  investigate  whether  they  are  to  be  found  in  all  cases  of  cholera,  and 
whether  thev  are  absent  in  all  other  cases;,  that  is,  whether  they  belong  exclusively 
to  cliolera.  'in  this  direction  as  large  a  series  of  cases  as  possible  was  thoroughly 
investigated.  In  Egypt,  ten  post  mortem  examinations  could  be  turned  to  ac- 
count. It  is  true  the^se  were  only  microscopically  examined;  for  I  was  not  then 
sufficiently  acquainted  with  the  qualities  of  the  comma-bacilli,  which  they  show 
while  growing  in  food  gelatine,  to  be  able  to  make  use  of  the  gelatine-process  for 
proving  the  presence  of  the  bacilli.  But  I  was  convinced  by  careful  microscopic 
investigation  of  the  presence  of  the  comma-bacilli  in  all  these  cases.  In  India, 
forty-two  jjosf  mortem  examinations  were  made,  both  microscopically  and  by 
cultivations  in  food  gelatine,  and  in  no  case  were  the  bacilU  absent.  In  a  series 
of  cases,  which  had  been  very  acute,  an  almost  pure  cultivation  of  comma-bacilli 
was  met  with  in  the  intestinal  canal.  Further,  in  India,  the  dejecta  of  thirty-two 
cholei-a  patients  were  similarly  examined,  and  each  time  comma-bacilli  were 
present  in  them.  The  liqviid  vomit  of  cholera  patients  was  also  often  examined; 
but  comma-bacilli  were  only  found  twice  in  the  vomit,  and  in  these  cases  the 
quality  of  the  vomit  enabled  us  to  conclude  that  it  was  not  properly  the  contents 
of  the' stomach,  but  contents  of  the  intestine,  which  had  been  driven  upward  by 
abdominal  pressure,  and  evacuated.  The  licjuid  had  an  alkaline  reaction  and 
looked  exactly  like  the  contents  of  the  intestine.  I  have  also  found  comma-bacilli 
in  eight  other  2^ost  mortem  preparations,  some  of  which  I  had  previously  had 
sent  me  from  India,  and  othei-s  I  had  received  from  Alexandria,  from  Dr.  Kar- 
tulis  and  Dr.  Schiess  Bey.  Finally,  I  recently  made  two  2^ost  mortem  examina- 
tions at  Toulon,  together  with  Dr.  Straus  and"  Dr.  Roux;  and  in  these  cases  also, 
as  well  as  in  the  dejecta  of  two  patients,  comma-bacilli  were  found.  In  these  two 
2iost  mortem  examinations  at  Toulon  we  had  to  do  with  exceptionally  character- 
istic and  acute  cases.  One  of  the  men,  a  sailor,  was  to  have  been  dismissed  from 
the  hospital  on  the  same  day,  as  convalescent  from  malaria;  but  this  could  not  be 
done,  for  at  about  eleven  o'clock  in  the  morning  he  had  an  attack  of  cholera.  He 
died  in  the  afternoon  at  three,  and  the  corpse  could  be  dissected  by  half-past  three. 
I  will  here  observe  that  in  almost  all  the  cases  examined  by  me  the  i^ost  mortem 
examinations  have  been  made  a  very  short  time  after  death.  We  have  often 
made  the  dissections  immediately  after  death;  in  most  cases  two  or  three  hours, 
at  latest,  after  death;  fio  ihixt  post  mortem  putrefaction  could  not  yet  have  had 
the  effect  of  changing  the  condition  of  tlie  intestine  or  of  its  contents.  In  the 
case  mentioned,  as  in  those  of  a  nujuber  of  earlier  post  mortem  examinations,  we 
could  also  convince  ourselves  of  the  presence  in  the  intestine,  in  very  acute 
cases,  of  almost  a  pure  cultivation  of  comma-bacilli.  I  was  able  to  demon- 
strate this  fact  to  Dr.  Straus  and  Dr.  Roux,  who  had  not  as  yet  succeeded  in 
proving  the  existence  of  comma-bacilli  either  microscopically  or  on  firm 
nutritive  soil.  These  gentlemen  had  always  been  of  opinion.  Dr.  Straus 
told  me.  that  a  special  trick  in  the  preparation  was  necessary  in  order  to  color  and 
cultivate  the  conmiivbacilli.  Then,  how^ever>  they  were  convinced  that  nothing 
is  more  simple  than  this,  if  only  a  pure  and  uncomplicated  case  be  chosen  for  in- 
vestigation. 

In  the  second  post  mortem  examination,  also,  in  which  I  took  part  at  Toulon, 
the  comma-bacilli  were  found  in  the  intestine  in  almost  a  pure  cultivation.  I 
then  asked  Dr.  Straus  to  take  this  opportunity  of  showing  me  the  micro-organisms 
which,  according  to  his  view,  are  to  be  found  in  cholera  blood.  But  these  ap- 
pearances were  not  to  be  found  in  either  case. 

If  we  add  all  these  cases  together,  nearly  one  hundred  have  been  examined  with 
regard  to  the  presence  of  comma-bacilli,  and  the  bacilli  have  been  found  in  all  of 
them.  But  the  investigation  has  not  only  proved  the  existence  of  the  comma- 
baciUi,  but,  as  I  have  repeatedly  hinted,  they  always  stand  in  exact  proportion  to 
the  cholera-process  itself;  for,  "where  the  real  cholera-process  proper  caused  the 
greatest  modifications  in  the  intestine,  namely,  in  the  lower  section  of  the  small 
intestine,  they  were  to  be  found  in  greatest  numbers;  from  these  upward  they 
diminished  more  and  more.  In  the  least  complicated  cases,  they  appeared 
almost  like  pure  cultivations.  The  older  the  case,  and  the  more  secondary  modi- 
fications have  taken  place  in  the  intestine,  the  more  do  tliey  recede  into  the  back- 
ground. 


ASIATIC  CHOLERA.  KJI 

In  accordance  with  the  cholera  material  that  I  have  so  far  examined,  I  think  I 
can  now  assert  that  comma-bacilli  are  never  absent  in  cases  of  cholera;  they  are 
something'  that  is  specific  to  cholera. 

As  a  test,  a  considerable  number  of  other  corpses,  dejecta  from  patients  and 
persons  in  good  health,  and  other  substances  containing  bacteria,  were  examined 
to  see  if  these  bacilli,  which  were  never  missing  in  cases  of  cholei-a,  might,  per- 
haps, occur  elsewhere  also.  This  is  a  point  of  the  greatest  importance  la  judg'ing 
the  causal  connection  between  comma-bacilli  and  cholera. 

Among  these  objects  for  investigation  was  the  corpse  of  a  man  who  had  had 
cholera  six  weeks  before,  and  had  afterward  died  of  anaemia.  There  was  no 
further  trace  of  comma-bacilli  to  be  found  in  his  intestines.  The  dejecta  of  a 
man  who  had  had  an  attack  of  cholera  for  eight  days  previoush'  were  also  ex- 
amined; liis  stools  were  already  beginning  to  be  consistent;  in  this  case  also 
comma-bacilli  were  absent. 

I  have  also  thoroughly  examined  more  than  thirty  corpses,  in  order  to  convince 
myself  more  and  more  that  these  bacilli  are  reallj^  only  found  in  cases  of  cholera. 
Corpses  of  those  who  had  died  of  affections  of  the  intestines,  e.  g. ,  of  dysentery  or 
of  those  catarrhs  of  the  mtestines  frequently  mortal  in  the  tropics, were  selected  for 
this  piu'pose;  also  cases  with  ulceration  in  the  intestine,  a  case  of  enteric  fever, 
and  several  cases  of  bilious  typhoid. 

In  the  last-named  disease,  the  modifications  in  the  intestines  are  at  first  sight 
very  similar  to  those  which  take  place  in  severe  cases  of  cholera,  in  which  henior- 
rhage  of  the  intestine  occui-s.  The  small  intestine  is  in  the  lower  section  infil- 
trated by  hemorrhage;  but,  sti-ange  to  say,  this  change  affects  rather  the  Peyer's 
patches  in  bilious  typhoid,  while  in  cholera  they  are  very  little  changed. 

In  all  these  cases  where  we  had  to  deal  chiefly  with  diseases  of  the  intestine, 
no  trace  of  comma-bacilli  was  to  be  found.  Experience  teaches  that  such  affec- 
tions of  the  intestine  make  people  especially'  liable  to  cholera.  So  one  might  have 
presupposed  that  comma-bacilli,  if  they  were  to  be  found  anywhere  else,  must  be 
found  in  these  cases.  Beside  these,  dejecta  of  a  large  number  of  dysenteric 
patients  were  examined  ^^^thout  the  comma-bacilli  ever  being"  met  with.  AVe 
continued  these  investigations  afterward  in  Berlin,  and  examined  a  con- 
sidei-able  number  of  various  dejecta,  especiall}'  of  children's  diarrhoea,  as  well  as 
that  of  grown-uii  persons;  saliva  also,  and  the  mucus  that  adheres  to  the  teeth 
and  tongue,  and  which  abounds  in  bacteria,  for  the  purpose  of  finding  comma- 
bacilli,  but  always  without  success.  Various  animals  were  also  examined  with 
this  \iew.  Because  a  complication  of  symptoms  very  similar  to  those  of  cholera 
can  be  obtained  by  arsenical  poisoning',  animals  wei-e  poisoned  with  arsenic,  and 
afterward  examined.  A  great  number  of  bacteria  were  found  in  the  intestines, 
but  no  comma-bacilli.  Nor  were  they  found  in  the  sewage  from  the  drains  of  the 
town  of  Calcutta,  in  the  extremely  polluted  water  of  the  river  Hoogly,  in  a  num- 
ber of  tanks  which  lie  in  the  villages  and  between  the  huts  of  the  natives,  and 
contain  very  dirty  water.  Eveiy  where,  where  I  was  able  to  come  across  a  li([uid 
containing  bacteria,  I  examined  it  in  search  of  comma-bacilli,  but  never  found  them 
in  it.  Only  once  did  I  come  aci-oss  a  kind  of  bacterium  which  at  first  sight  bore  a 
strong  resemblance  to  comrna-bacilli,  and  that  was  in  the  water  which,  at  high 
water,  floods  the  land  of  the  salt  water  lake  that  lies  to  the  east  of  Calcutta;  but, 
on  a  closer  inspection,  they  appeared  larger  and  thicker  than  comma-bacilli,  and 
their  culture  did  not  liquefy  gelatine. 

Beside  these  observations,  I  have  had  a  considerable  expei'ience  in  bacteria,. 
I)ut  I  cannot  remember  ever  having  seen  bacteria  resembling  the  comma-bacilli. 
I  have  spoken  to  several  people  who  have  made  a  great  number  of  cultivations  of 
bacteria,  and  have  also  had  experience,  but  all  have  told  me  that  they  have  not 
yet  seen  sucli  bacteria.  I  therefore  think  I  may  say  positively  that  the  comma- 
bacilli  are  constant  concomitants  of  the  cholei-a  process,  and  that  they  are  never 
found  elsewhere. 

The  question  to  be  answered  now  is,  how  we  are  to  represent  the  relation  be- 
tween the  comma-bacillus  and  the  cholera-process.  In  answering  this  question, 
three  different  assumptions  may  be  made.  It  can  be  said,  first,  that  the  cholera- 
process  favors  the  growth  of  comma-bacilli  by  preparing  the  nutritive  soil  for 
them,  and  that,  consequently,  so  striking  an  Increase  of  precisely  this  kind  of 
bacteria  takes  place.  If  this  assertion  be  made,  then  one  must  start  with  the 
presupposition  that  everybody  already  has  comma-bacilli  in  his  body  at  the  time 
when  he  is  attacked  by  cholera;  for  they  were  found  in  the  most  various  places 
in  India,  in  Egvpt,  in  France,  and  in  people  of  most  various  origin  and  nationality. 
11 


IQ2  THE   DOCTRINE   OF  KOCH. 

On  this  assxrmption,  this  kind  of  bacteria  must  be  one  of  tlie  most  AA-idely  spread 
and  most  usual  kind.  But  the  contraiy  is  the  fact;  for  they  are  not  found,  as  we 
have  seen,  eitlier  in  those  persons  who  are  suffering-  from  other  diseases,  or  in 
persons  in  good  health,  or,  except  in  man,  in  places  favorable  for  the  development 
of  bacteria;  they  are  always  found  only  where  cholera  is  prevaihng.  This  as- 
sumption cannot,  therefore,  be  regarded  as  admissible,  and  must  be  dropped. 

Secondly,  one  might  tiy  to  explain  the  regular  concurrence  of  comma-bacilli 
and  the  cholera  process  in  this  way:  that  conditions  are  created  by  the  disease,  by 
means  of  which,  among  the  many  bacteria  that  are  to  be  found  in  the  intestine, 
one  kind  or  another  is  changed,  and  assumes  the  qualities  that  we  have  observed 
in  the  comma-bacillas.  But,  in  regard  to  this  explanation,  I  must  confess  that  it 
has  no  actual  foundation  whatever,  and  is  a  pure  hypothesis.  So  far,  we  know  of 
no  ti"ansformation  of  one  kind  of  bacteria  into  another.  The  sole  instances  of 
ti'ansformation  in  the  qualities  of  bacteria  rest  on  their  physiological  and  patho- 
genic effects,  not  on  their  form.  Anthrax-bacilli,  for  instance,  when  treated  in  a 
particular  manner,  lose  their  pathogenic  effect,  but  they  remain  quite  unchanged 
in  form.  In  this  instance  we  have  an  example  of  loss  of  pathogenic  qualities. 
But  this  is  precisely  the  opposite  of  what  would  take  place  by  the  transformation 
of  harmless  intestinal  bacteria  into  dangerous  cholera-bacilli.  Of  this  latter  kind 
of  change  from  harmless  into  harmful  bacteria,  there  is  no  instance  that  has  ever 
been  shown.  Some  years  ago,  when  the  investigation  of  bacteria  was  only  in  its 
first  stage,  such  an  hypothesis  might  with  some  degree  of  justification  have  been 
made.  But  the  further  the  knowledge  of  bacteria  has  developed,  the  more  certain 
has  it  been  shown  that,  in  regard  to  shape,  bacteria  are  extraordinarih'  constant. 
With  special  reference  to  comma-bacilli,  I  will  further  remark  that  they  retain 
the  qualities  above  described  when  raised  outside  the  human  body.  For  instance, 
they  were  repeatedly  cultivated,  from  one  to  another  cultivation,  in  gelatine,  to 
the  number  of  twenty  cultivations,  and  must  have  returned  to*  the  known  forms 
of  the  common  intestinal  bacteria  if  they  were  not  as  constant  in  their  quaUties 
as  other  bacteria;  but  this  was  by  no  means  the  case. 

There  only  remains  the  third  assumption — namely,  that  the  cholera  process 
and  the  comma-bacilli  stand  in  immediate  connection  witli  one  another;  and,  in 
this  respect,  I  know  of  no  other  supposition  than  that  the  comma-bacilli  are  the 
cause  of  the  cholera  process;  that  they  precede  the  disease,  and  that  thej^  pro- 
duce it.  The  opposite  would  be,  what  I  have  just  explained,  that  the  cholera 
process  produces  the  comma-bacilh;  and  this  is,  as  was  shown,  not  possible.  As 
far  as  I  am  myseK  concerned,  the  matter  is  clear,  that  the  comma-bacilli  are  the 
cause  of  cholera. 

Now  it  can  certainly  be  demanded  that,  if  this  be  the  case,  further  proofs 
should  be  brought  in  sujpport  of  it,  and  above  all,  that  the  cholera  process  should 
be  produced  experimentally  by  means  of  the  comma-bacilli.  Every  imaginable 
effort  has  therefore  been  made  to  meet  this  demand.  The  only  possible  way  of 
giving  such  a  direct  proof  of  the  cholera-producing  effect  of  comma-bacilli  is  to 
make  experiments  on  animals,  which,  if  we  are  to  believe  the  statements  of 
writere  on  the  subject,  can  be  done  without  anj-  difficulty.  It  has  been  said  that 
cases  of  cholera  occurred  among  cows,  dogs,  poultry,  elephants,  cats  and  several 
other  animals;  but  on  closer  examination  these  statements  are  found  to  be  quite 
unreliable.  As  yet  we  have  no  certain  instance  of  animals  falling  spontaneously 
ill  of  cholera  in  "^periods  of  cholera.  All  experiments,  also,  which  have  hitherto 
been  made  on  animals  ^\ith  cholera  substances  have  either  given  a  negative 
result  or,  if  thej'  were  said  to  give  a  positive  result,  they  were  not  sufficienth' 
supported  by  evidence,  or  were  disputed  by  other  experimenters.  AVe  occupied 
ourselves,  nevertheless,  in  the  most  careful  and  detailed  mannei',  with  experi- 
ments on  animals.  Because  great  value  must  be  laid  on  the  results  on  white  mice 
obtained  by  Thiei-sch,  I  took  fifty  mice  with  me  from  Berlin,  and  made  all  kinds 
of  experiments  on  them,  at  first  feeding  them  on  the  dejecta  of  cholera  patients 
and  the  contents  of  the  intestine  of  cholera  corpses.  We  followed  Thiersch's  rules 
as  accurateh'  as  possible,  not  only  feeding  them  with  fresh  material,  but  also  with 
the  same  food  after  the  fluids  had  began  to  decompose.  Although  these  experi- 
ments were  constantly  repeated  witli  material  from  fresh  cholera  cases,  our  mice 
remained  healtlij'.  We  then  made  ex])eriments  on  monkej-s,  cats,  poultry,  dogs, 
and  various  other  animals  tiiat  we  were  able  to  get  hold  of;  but  we  were  never 
able  to  arrive  at  anything  in  animals  similar  to  the  cholera  process.  In  precisely 
the  same  manner  we  made  experiments  with  the  cultivations  of  comma-bacilli; 
these  were  also  given  as  food  in  all  stages  of  development.     When  experiments 


ASIATIC  CHOLERA.  163 

Avere  made  by  feeding-  the  animals  with  large  quantities  of  comma-bacilli,  on  kill- 
ing them  ami  examining  the  contents  of  their  stomachs  and  intestines  with  a 
view  to  find  comma-bacilli,  it  was  s(>en  that  the  comma-bacilli  had  already 
perished  in  the  stomach,  and  had  usually  not  reached  the  intestinal  canal.  Otlier 
bacteria  are  different  in  this  respect,  for  a  beautifully  red  colored  micrococcus  was 
found  accidentally  at  Calcutta,  which  was  easily  recog^nized  by  its  striking  color, 
and  was  therefore  especially  suitable  for  such  an  experiment.  This  micrococcus 
was,  at  my  request,  given  by  Dr.  Barclay,  of  Calcutta,  to  mice  as  food,  and  the 
contents  of  the  intestines  of  "these  animals  were  placed  upon  potatoes.  The  red 
colonies  of  the  micrococcus  again  foi-med,  which  had  thus  passed  the  stomach  of 
the  mouse  uninjm'ed.  On  the  other  hand,  comma-bacilli  are  destroyed  in  the 
stomachs  of  animals.  "We  were  forced  to  conclude  from  this  that  the  failure  of 
these  experiments  by  feeding  the  animals  was  due  to  this  property  of  the  comma- 
bacilli.  The  experiment  was  therefore  modified  by  introdvicing  the  substances 
direct  into  the  intestines  of  the  animals.  The  belly  was  opened  and  the  Uquid  was 
injected  immediately  into  the  small  intestine  with  a  Pravaz  syring-e.  The  ani- 
mals bore  this  very  well,  but  it  did  not  make  them  ill.  We  also  ti-ied  to  bring  the 
cholera-dejecta  as  high  as  possible  into  the  intestines  of  monkeys  by  means  of  a 
long  catheter.  This  succeeded  very  well,  but  the  annuals  did  not  sivffer  from  it. 
I  must  also  mention  that  purgatives  wei-e  previously  administered  to  the  animals 
in  order  to  put  the  intestine  into  a  state  of  irritation,  and  then  the  infecting  sub- 
stance was  given  without  obtaining  any  different  result.  The  only  expermient 
in  which  the  comma-bacilli  exhibited  a  pathogenic  effect,  which  therefore  gave 
me  hope  at  first  that  we  should  arrive  at  some  result,  was  that  in  which  pure  cul- 
tivations were  injected  directly  into  the  blood-vessels  of  rabbits  or  into  the  ab- 
dominal cavity  of  mice.  Rabbits  seemed  very  ill  after  the  injection,  but  recovei'ed 
after  a  few  days.  Mke,  on  the  contrai-y,  died  from  twenty-four  to  forty-eight 
houi-s  after  the  injection,  and  comma-bacilli  were  found  in  their  blood. 

Of  coui'se,  they  must  be  administered  to  animals  in  large  quantities;  and  it  is 
not  the  same  as  in  other  experiments  connected  with  infection,  where  the  small- 
est quantities  of  infectious  matter  are  used  and  yet  an  effect  is  produced.  In  or- 
der to  arrive  at  certainty  whether  animals  can  be  infected  with  cholei'a,  I  made 
inquiries  everywhere  in  India  whether  similar  diseases  had  ever  been  remarked  in 
India  among  animals.  In  Bengal  I  was  assured  such  a  phenomenon  had  never 
occurred.  This  province  is  extremely  thickly  populated,  and  there  are  many 
kinds  of  animals  there  which  live  together  with  human  beings.  One  would  sup- 
pose, then,  that  in  this  country,  where  cholera  exists  in  all  parts  of  it  continuously, 
animals  must  often  i-eceive  into  their  digestive  canal  the  infectious  matter  of 
cholera,  and  indeed,  in  just  as  effective  a  form  as  hviman  beings,  but  no  case  of 
an  animal  having  an  attack  of  cholera  has  ever  been  observed  there.  Hence  I 
think  that  all  the  animals  on  which  we  can  make  experiments,  and  all  those,  too, 
which  come  into  contact  with  human  beings,  are  not  liable  to  cholera,  and  that  a 
real  cholera  process  cannot  be  artificially  produced  in  them.  We  must,  therefore, 
dispense  witli  them  as  a  material  for  affording  proofs. 

But  with  this  I  do  not  by  any  means  intend  to  say  that  no  proof  at  all  can  be 
brought  of  the  pathogenic  action  of  comma-bacilli.  I  have  already  explained  to 
you  tiiat,  for  my  own  part,  I  can  form  no  other  idea,  even  without  these  exj^eri- 
ments  on  animals,  than  that  a  causal  connection  exists  between  the  comma- 
bacilli  and  the  cholera  process.  Should  it  prove  possible  later  on  to  produce  any- 
thing similar  to  cholera  in  animals,  that  would  not,  for  me,  prove  anji;hing  more 
than  the  facts  which  we  now  have  before  us.  Besides,  we  know  of  other  diseases 
which  cannot  be  transfei-red  to  animals,  e.g.,  leprosy;  apd  j-et  we  must  admit, 
from  all  that  we  know  of  leprosy-bacilli,  that  they  are  the  cause  of  the  disease. 
For  this  disease,  also,  we  must  dispense  with  experiments  on  animals,  because  as 
yet  no  species  of  animals  has  been  found  susceptible  to  leprosy.  It  is  probably 
the  same  with  enteric  fever;  I  do  not  know  that  any  one  has  ever  succeeded  in  in- 
fecting animals  with  it.  We  must  be  satisfied  with  the  fact,  that  we  verify 
the  constant  presence  of  a  pai-ticular  kind  of  bacteiia  in  the  disease  in  question, 
and  the  absence  of  the  same  bacteria  in  other  diseases.  The  bacteria  in  question 
must  always  coincide  exactly  with  the  infectious  principle  of  this  particular  dis- 
ease, and  to  this  point  I  attach  great  value;  the  presence  of  pathogenic  bacteria 
must  be  one  corresponding  to  the  pathological  transformations  in  the  body,  and 
to  the  course  of  the  disease.  On  the  other  hand,  we  know  of  diseases  of  animals, 
also,  which  cannot  be  transferred  to  himian  beings;  for  example,  rinderpest  and 
pneumonia  of  cattle.     We  meet  here  with  a  phenomenon  widely  spread  in  nature. 


1IJ4  THE   DOCTRINE  OF  KOCH. 

Almost  all  parasites  are  restricted  to  only  one  or  very  few  species  of  aniuuils, 
which  act  as  their  host.  I  remind  you  of  tapeworms;  many  kinds  of  animals 
have  their  own  special  tapeworm,  which  can  only  develop  in  one  species  of  animal, 
and  in  no  otiier. 

We  must,  therefore,  dispense  with  this  part  of  the  proof  in  a  large  number  of 
infectiovis  diseases,  which  number  also  includes  the  exanthematic  diseases;  and  we 
can  do  this  the  more  readily,  because  we  already  know  a  whole  series  of  other 
diseases,  which  are  caused  by  pathogenic  organisms,  in  which,  however  the  con- 
ditions in  other  respects  are  the  same,  and  of  which  we  know  with  perfect  certainty 
that  the  disease  is  occasioned  by  the  micro-organisms  belonging  to  tliese  dis- 
eases while  we  have  never  j'et  seen  that  the  disease  produces  a  specific  micro-or- 
ganism. I  think  that,  after  having  become  acquainted  with  a  wliole  series  of 
such  diseases  caused  by  micro-parasites,  we  are  justified  in  drawing  an  analo- 
gous conclusion. 

13ut,  further,  some  observations  are  before  us  which  are  as  good  as  experi- 
ments on  human  being-s.  We  can  look  upon  them  as  complete  experiments 
wliicli  have  taken  place  under  natural  conditions.  The  most  important  of  these 
observations  is  the  infection  of  those  persons  who  are  occvipied  in  liandling- 
cholera  linen.  I  have  often  had  an  opportunity  of  examining  cholera-linen  and 
have  always  found  the  comma-bacilli  in  enormous  numbers,  and  generally  in  a 
regular  pui'e  cultivation,  in  tlie  mucous  substance  which  is  found  on  the  surface 
of  the  linen  soiled  by  the  dejecta. 

If,  therefore,  an  infection  can  be  brought  about  by  cholera  linen,  then,  as  the 
comma-bacilli  are  the  only  micro-organisms  in  question,  it  can  only  be  brought 
about  by  tliem.  Whether  the  transmission  was  brought  about  by  the  laundress 
bringing  her  hands  soiled  with  comma-bacilli  into  contact  with  her  food  or  directly 
with  her  mouth,  or  by  the  water  that  contained  bacilli  splashing  and  some 
drops  of  it  reaching  the  lips  or  mouth  of  the  laundress,  in  any  case  the  conditions 
are  the  same  here  as  in  an  experiment  in  which  a  human  being  is  fed  with  a 
small  quantity  of  a  pure  cultivation  of  comma-bacilli.  It  is  indeed  an  experiment 
wliich  a  human  being  unconsciously  performs  on  himself,  and  the  same  demon- 
strative power  lies  in  it  as  if  it  had  been  intentionally  made.  This  observation 
has  furthermore  been  frequently  made  and  by  vei-y  various  medical  men,  so 
that  there  can  be  absolutely  no  doubt  of  their  trustworthiness.  I  can,  besides, 
appeal  to  an  observation  of  my  o^\^l  on  this  point.  I  succeeded  in  finding  comma- 
bacilli  witli  all  tlieir  characteristic  peculiarities  in  a  tank  that  supplies  water  for 
drinking  and  liousehold  purposes  for  all  the  people  living  around,  in  the  immedi- 
ate neighborhood  of  which  a  number  of  fatal  cases  of  cliolera  had  taken  jilace.  It 
was  later  siiown  that  the  linen  of  the  first  person  that  had  died  of  cholera  in  tlie 
neighborhood  of  this  tank  had  been  vvasiied  in  the  tank.  Tliat  is  the  onlj'  time  that 
I  have  as  yet  been  able  to  find  the  comma-bacilli  outside  the  Imman  body.  On  the 
bank  of  this  tank  there  were  30  or  40  huts,  in  which  from  300  to  300  people  lived; 
and  17  of  these  had  died  of  cholera.  It  could  not  be  ascertained  exactly  how 
many  had  been  taken  ill.  Such  a  tank  supplies  those  who  live  close  to  it  with 
water  for  drinking  and  liouseliold  purposes;  but  at  the  same  time  it  receives  all 
tiie  refuse  from  the  houses.  Tiie  Hindoos  bathe  in  it  every  day,  they  wash  tlieir 
utensils  in  it,  tlie  human  fajces  are  by  preference  deposited  on  its  banks,  and 
wlien  a  hut  is  provided  with  a  cesspool  it  drains  into  the  tank.  This  was  pre- 
cisely the  case  witli  the  tank  in  question.  When  the  comma-bacilli  were  first 
found  in  tolerably  large  numbers  and  at  different  points  of  the  bank,  the  small 
epidemic  had  already  reached  its  maximum.  A  short  time  afterwai'd  when  only 
isolated  cases  occurred  tiie  comma-bacilli  were  only  to  be  found  at  one  spot,  and 
in  small  numbers.  When  they  were  first  found,  they  were  so  abundant  that  their 
number  could  not  have  depended  alone  on  the  dejecta  that  had  fiowed  into  the 
tank  and  on  the  wash  water  from  cliolera  linen;  an  increase  of  them  must  have 
taken  place.  On  tlie  second  investigation,  on  tiie  other  hand,  their  small  num- 
ber did  not  correspond  to  the  numerous  cases  of  illness  that  had  pi-eceded.  If 
the  latter  had  supplied  the  tank  water  with  bacilli,  the  bacilli  must  have  been 
far  more  numerous  this  time,  in  comparison  with  tlie  first  time  they  were  dis- 
covered. Hence  it  cannot  be  said  in  this  case  that  the  presence  of  the  comma- 
bacilli  in  the  tank  was  only  a  consequence  of  the  cholera  epidemic.  The  rela- 
tion was  such  that  the  epidemic  must  have  been  a  consequence  of  the  bacilli.  We 
must  lay  the  greater  value  on  observations  of  this  kind,  especially  on  tlie  infec- 
tion through  cholera  linen,  because  we  shall  perhaps  never  be  in  a  position  to 
make  direct  successful  infection-experiments  with  comma-bacilli. 


THE  DOCTRINE  OF  KOCH.  Ig5 

The  fact  that  the  etiology  of  cholera,  so  far  as  it  is  known  to  us,  agi'ees  com- 
pletely with  the  peculiarities  of  comma-bacilli  is,  I  consider,  an  essential  support 
of  my  theorj'^  that  these  microbes  are  tlie  cause  of  cholera. 

We  have  seen  that  comma-bacilli  g-row  very  rapidly;  that  their  vegetation 
quickly  reaches  its  maximum,  then  ceases;  and  that  the  bacilli  are  finallj'  driven 
away  by  otiier  bacteria.  This  coiTesponds  exactly  to  what  takes  place  in  the  in- 
testines. 

It  can  be  assumed  that,  just  as  in  the  case  of  other  bacteria,  very  few  individu- 
als are  sufficient — under  certain  circumstances,  one  single  one — to  cause  infection. 
Accordingly,  we  can  very  well  imagine  that  individual  comma-bacilli  reach  the 
intestinal  canal  accidentall3^  and  speedily  multiply  there.  As  soon  as  they  have 
multiplied  to  a  certain  degree,  they  occasion  a  state  of  irritation  of  the  mucous 
membrane  of  the  intestine  and  diarrhoea:  but  when  the  multiplication  continues 
in  increasing  progression,  and  reaches  the  maxinium  point,  then  there  occurs  a 
culmination  into  the  peculiar  complex  of  symptoms  that  we  characterize  as  the 
real  attack  of  cholera. 

We  have  already  seen  that  comma-bacilli  most  probably,  vinder  certain  con- 
ditions, cannot  pass  the  stomach,  at  least  in  animals.  Tliis  also  agrees  with  all 
experience  of  cholera,  for  predisposition  seems  to  play  an  important  part  in  cholera 
infection.  It  can  be  assmiied  that,  of  a  number  of  people  exposed  to  cholera  in- 
fection, only  a  fraction  of  them  fall  ill,  and  these  are  ahuost  always  those  already 
suffering  from  some  kind  of  digestive  disturbance,  e.  g. ,  catarrh  of  the  stomach 
or  intestines,  or  those  who  have  overloaded  the  stomach  with  indigestible  food. 
Especially  in  the  latter  case,  more  or  less  undig-ested  masses  of  food  maj' pass  into 
the  intestinal  canal,  and  possibly  bring  with  them  the  comma-bacilli  not  yet  killed 
in  the  stomach.  You  have  doubtless  often  observed  that  tlie  greater  number  of 
cases  of  cholera  occur  on  Mondays  and  Tuesdays — that  is,  on  the  days  which  have 
generally  been  preceded  by  excesses  in  eating  and  drinking. 

It  is  certainly  a  strange  phenomenon,  that  comma-bacilli  confine  themselves 
to  the  intestines.  They  do  not  pass  into  the  blood,  nor  even  into  the  mesenteric 
glands.  How  is  it  now  that  tliis  bacterial  vegetation  in  the  intestine  can  kill  a 
man?  In  order  to  explain  this  Koch  calls  attention  to  the  fact  that  bacteria, 
when  they  grow,  not  only  consume  materials,  but  also  produce  substances  of 
very  various  kinds.  "We  know  a  great  many  products  of  tlie  vital  action 
of  bacteria,  which  are  of  a  very  peculiar  nature.  Many  of  them  are  of  a  tran- 
sient nature,  and  emit  an  intense  smell;  others  produce  coloring-  matter,  othei-s 
poisonous  substances.  In  the  putrefaction  of  albuminovis  liquids,  e.  g.,  blood, 
poisons  are  formed  which  must  be  products  of  vital  changes  of  these  bacteria,  as 
putrefaction  is  only  a  consequence  of  the  growth  of  bacteria.  Many  phenomena 
go  to  show  that  these  poisons  are  only  produced  by  special  kinds  of  bacteria,  for 
we  see  that  putrefying-  fluids  can  at  times  be  injected  into  an  animal  without  pro- 
ducing any  eft'ect,  whereas  at  other  times  they  prove  decidedly  poisonous.  In  this 
light,  I  picture  to  myself  the  effect  of  comma-bacilli  in  the  intestine,  which  de- 
pends upon  the  products  of  vital  changes.  In  favor  of  this  view,  I  possess  sjjecial 
points  of  support.  It  so  happened  that  in  one  cultivation  expeiiment,  the  nutri- 
tive gelatine  contained  at  the  same  time  blood  corpuscles  in  tolerably  large 
numbers  and  comma-bacilli.  After  this  gelatine  had  been  poured  upon  a  plate,  a 
number  of  colonies  of  comma-bacili  grew.  The  plate  looked  as  if  a  reddisli  dust 
were  suspended  in  it,  as,  when  the  light  fell  through  it,  one  had  a  clear  impression 
of  the  single  blood-corpuscles.  In  this  reddish,  finely  granular  layer,  the  colonies 
of  comma-bacilli  looked  to  the  naked  eye  like  small  colorless  holes.  When  they 
were  examined  under  the  microscope,  the  striking  phenomenon  was  discovered 
that  the  colonies  of  comma-bacilli  had  destroyed  all  tlie  blood-corpuscles  within  a 
pretty  wide  circle,  and  also  to  some  distance  beyond  the  limit  within  whicli  they 
had  liquefied  the  gelatine.  From  this  it  is  seen  that  comma-bacilli  can  exercise  a 
destructive  influence  on  the  formed  elements  of  the  blood,  and  very  probably  also 
on  other  cells. 

Mr.  Richards,  a  medical  man  at  Goalundo,  in  India,  has  also  made  an  observa- 
tion which  supports  the  view  of  the  presence  of  a  poisonous  substance  in  tlie  con- 
tents of  the  cholei-a  intestine.  Mi'.  Richards  fed  some  dogs  with  large  quantities 
of  cholera  dejecta,  without  producing  any  effect  on  the  dogs.  Then  he  made  the 
same  experiment  with  pigs,  which,  according  to  his  statement,  died  in  cramps  a 
very  short  time  (fi'om  a  quarter  of  an  hour  to  two  hours  and  a  half)  after  being- 
fed.  This  was  clearly  a  case  of  poisoning,  and  not,  as  Mr.  Richards  supposes,  of 
artificial  cholera  infection.     That  this  was  really  so,  is  especially  seen  from  one  of 


IQQ  ASL\TIC  CHOLERA. 

the  experiments,  in  which  the  contents  of  the  intestine  of  a  pig,  killed  by  being- 
fed  on  cholera  dejecta,  which,  according  to  Mr.  Richards'  opinion,  had  the  cholera, 
were  given  to  another  pig.  This  second  pig  did  not  suffer  from  it,  so  that  a  re- 
production of  the  supposed  infectious  matter  in  the  intestine  of  the  pig  fed  first 
could  not  have  taken  place.  If  genuine  cholera  could  be  produced  among  pigs,  it 
would  then  be  possible  to  infect  a  second  pig  with  the  contents  of  the  intestine  of 
the  first,  and  a  third  with  those  from  the  second,  and  so  on.  Although  these  ex- 
periments do  not  prove  what  Mr.  Richards  intended  to  prove  by  them,  they  are 
interesting,  in  so  far  as  they  show  that,  in  cholera-dejecta,  substances  can 
under  certain  circumstances  be  contained,  which  are  poisonous  to  pigs.  Dogs 
seem  to  be  unaffected  by  them;  mice  and  other  animals  also,  as  our  experiments 
showed.  The  power  of  resistance  of  otlier  animals  to  this  poison,  and  the  suscepti- 
bility of  pigs  to  it.  ought  to  cause  no  surpmse.  when  we  remember  that  only  pigs 
seem  to  be  killed  by  the  poison  which  sometimes  forms  in  the  brine  of  salt  meat 
and  herrings. 

Supposing  that  comma-bacilli  produce  a  special  poison,  the  phenomena  and 
course  of  cholera  can  be  explained  as  follows:  The  effect  of  the  poison  shows 
itself  partly  in  an  immediate  manner,  the  epithelium,  and  in  the  worst  cases  also 
the  vipper  layers  of  the  mucous  membrane  of  the  intestine,  being  mortified  there- 
bj^;  it  is  partl3'  reabsorbed  and  acts  on  the  organism  as  a  whole,  but  especially  on 
the  organs  of  circulation,  which  are  as  it  were  paralyzed.  The  complex  of  symp- 
toms of  the  attack  proper  of  cholera,  w-hich  is  generally  looked  upon  as  a  con- 
sequence of  loss  of  water  and  the  inspissation  of  the  blood,  is,  according  to  my 
opinion,  to  be  regarded  essentially  as  poisoning;  for  it  takes  place  not  infrequent- 
ly when  comparatively  vei'y  small  quantities  of  fluid  are  lost  during  life  by 
vomiting  and  diari'hoca,  and  when,  immediately  after  death,  the  intestine  also 
contains  only  a  small  quantity  of  liquid. 

If,  now,  death  follow  in  the  stage  of  cholera  poisoning,  then  the  phenomena 
met  witli  in  j^ost-mortem  examinations  correspond  to  those  cases  in  which  the 
mucous  membrane  of  the  intestine  is  little  changed,  and  the  contents  of  the  in- 
testine consist  of  a  pure  cultivation  of  comma-bacilli.  If,  on  the  contrary,  this 
stage  be  prolonged,  or  if  it  be  got  over,  the  consequences  of  the  mortification  of 
the  epithelium  and  of  the  mucous  membrane  show  themselves;  capillary  hemor- 
rhage in  the  mucous  membrane  takes  place,  and  some  of  the  component  parts-of 
the  blood  mix  in  more  or  less  abundance  with  the  contents  of  the  intestine.  The 
albuminous  fluid  in  the  intestine  begins  to  putrefy,  and,  vinder  the  influence  of  the 
putrefaction-bacteria,  other  poisonous  products  are  formed  which  ai'fe  also  ab- 
sorbed. But  these  have  an  effect  differing  from  that  of  the  cholera  poison;  the 
symptoms  caused  by  them  correspond  to  what  is  generally  called  cholera-typhoid. 

Cori'esponding  to  the  view  that  the  comma-bacilli  only  vegetate  and  unfold 
their  effect  in  the  intestine,  the  seat  of  the  infectious  matter  can  only  be  looked 
for  in  the  dejecta  of  patients.  Exceptionally,  however,  they  may  be  found  in  the 
vomit.  In  this,  I  think  I  am  in  accord  with  the  more  I'ecent  views.  It  is  true 
that  this  view  is  still  contradicted  by  some  investigators,  but  we  are  in  possession 
of  incontrovertible  proofs  in  its  favor — above  all,  infection  by  means  of  linen;  so 
that,  quite  apart  from  the  comma-bacilli,  there  can  be  no  doubt  that  the  dejecta 
really  contain  the  infectious  matter.  For  the  further  spread  of  the  infectious 
matter,  the  first  condition  is  that  the  dejecta  remain  in  a  moist  condition.  As 
soon  as  they  are  diy,  they  lose  their  effectual  agency. 

One  of  the  commonest  ways  of  spreading  the  infectious  material  of  which,  too, 
we  have  had  an  example  in  the  tank  epidemic,  is  water.  How  easih'  can  cholera- 
dejecta  or  water  used  for  cleaning  cholera  linen  get  into  wells,  public  water- 
courses, and  other  places  for  the  supply  of  drinking-water  and  of  water  for  liouse- 
hold  purposes.  Thence  the  comma-bacilli  find  plenty  of  opportunities  of  returning 
into  the  human  household,  either  in  drinking-water  or  in  water  used  for  being 
mixed  with  milk,  for  cooking,  for  rinsing  pots  and  pans,  for  cleaning  vegetables 
and  fruit,  for  washing,  bathing,  etc. 

Beside  these  ways,  the  infectious  matter  can  enter  the  human  digestive  organs 
by  a  shorter  way;  for  comma-bacilli  can,  beyond  a  doubt,  retain  vitality  for  a 
considerable  time  on  articles  of  food  which  have  a  moist  surface,  and  it  can  easily 
be  supposed  that  they  are  not  rarely  brought  thither  by  being  touched  with  dirty- 
hands;  and  I  do  not  consider  it  at  all  impossible  tliat  tlie  infectious  matter  is 
transferred  to  food  by  means  of  insects — for  example,  by  common  flies.  In  most 
CEises,  cei'tainly,  the  infectious  matter  entei-s  the  soil  with  the  dejecta,  and  finds 
its  way,  somehow  or  other,  into  wells  or  tanks. 


THE   DOCTRINE  OF  KOCH.  IQJ 

I  start  with  the  assumption  tliat  only  moist  substances  and  those  of  most 
different  kinds  (I  do  not  by  any  means  confine  myself  to  drinking  water)  that  are 
polluted  in  any  way  by  moist  dejecta,  may  also  convey  the  infectious  matter  to 
the  body.  On  the  other  hand  I  do  not  think  that  the  infectious  matter  of  cholera 
can  keep  in  a  dry  state,  or,  which  is  the  same  thing,  that  it  can  be  transferred  by 
means  of  the  air.  For  the  dispersion  of  an  infectious  matter  can,  as  a  rule,  only 
take  place  by  means  of  the  air  when  dry,  and  in  the  form  of  dust.  Experience  is 
also  in  favor  of  the  view  that  the  infectious  matter  cannot  be  introduced  in  a  dry 
state,  for  we  know  that  hitherto  cholera  has  never  come  hither  by  means  of  goods 
on  the  way  from  India;  never  as  yet  have  letters  or  postal  packets  introduced 
cholera,  even  when  not,  as  is  now  frec£uently  done,  pierced  through  and  fumigated. 
If  the  origin  of  the  separate  epidemics  be  carefully  looked  into,  it  will  be  found 
that  cholera  has  never  reached  us  except  through  human  being's  themselves;  and 
although  people  have  not  succeeded  in  the  case  of  these  separate  epidemics  in 
tracing  the  individual  who  brought  the  infectious  matter,  one  must  not  conclude 
from  this  that  this  is  an  exception.  For  we  must  consider  that  it  is  not  only  the 
individual  who  dies  of  cholera,  or  who  has  an  unquestionable  attack  of  cholera, 
that  is  liable  to  transfer  infection,  but  that  all  possible  transitions  up  to  this  most 
violent  form  of  the  disease,  even  slight  attacks  of  diarrhoea,  take  place,  which  are 
probabl}'  just  as  capable  of  giving  infection  as  the  worst  case  of  cholera.  Of 
course  we  can  only  arrive  at  positive  certainty  on  this  important  point  when 
tiie  slightest  cases  have  been  proved  to  be  real  cases  of  cholera  by  detecting  the 
presence  of  comma-bacilli. 

The  important  question  still  remains  to  be  answered,  whether  the  infectious 
material  can  reproduce  or  multiply  itself  outside  the  human  body.  I  believe  that 
it  can.  As  the  comma-bacilli  grow  on  a  gelatine  plate,  as  they  can  grow  on  a 
piece  of  linen,  or  in  meat  broth,  or  on  potatoes,  they  must  also  be  in  a  position  to 
grow  in  the  open  air,  especially  as  we  have  seen  that  a  comparatively  low  tem- 
perature allows  them  to  develop.  I  would  not  certainly  assume  that  the  multipli- 
cation of  the  comma-bacilli  outside  the  human  body  takes  place  in  well  water 
or  river  water  without  any  assistance,  for  these  fluids  do  not  possess  that  con- 
centration of  nutritiovis  substances  which  is  necessary  for  the  growth  of  the 
bacilli.  But  I  can  easily  imagine  that,  although  the  whole  mass  of  the  water  lu 
a  tank  or  reservoir  is  too  poor  in  nutritious  substances  for  bacilli  to  flourish  in  it, 
yet  some  spots  may  contain  sufficient  concentration  of  nutritive  substances — for 
example,  those  spots  where  a  gvitter,  or  the  outlet  of  a  cesspool,  opens  into  the 
stagnant  water,  where  vegetable  matter,  animal  refuse,  etc.,  he,  and  are  exposed 
to  putrefaction  by  bacteria.  At  such  points,  a  very  active  form  of  life  can  develop. 

I  have  often  formerly  made  such  experiments,  and  it  has  frequently  happened 
that  a  specimen  of  water  contained  scarcely  any  bacteria,  wliile  remains  of  plants, 
especially  roots  or  fruits  swimming  in  it,  teemed  with  bacteria,  more  particularly 
bacilli  and  spirilla.  Even  in  the  immediate  neighborhood  of  these  objects,  the 
water  was  rendered  turbid  by  swarms  of  bacteria,  which  clearly  received  their 
noui'ishment  from  the  nutritive  matter  scattered  by  diftusion  at  a  very  small  dis- 
tance. 

I  think  that  we  can  in  this  way  most  readily  explain  the  relations  of  subsoil- 
water  to  the  spread  of  cholera.  Everywhere  where  water  is  stagnant  on  the  sur- 
face or  in  the  ground,  in  raai'shes,  in  harbors  which  have  no  outflow,  in  places 
where  the  ground  is  trough-shaped,  in  veiy  slowly  running  streams,  and  such  like, 
the  conditions  described  can  develop.  There,  in  the  neighborhood  of  animal  and 
vegetable  refuse,  concentrated  nutritive  solutions  will  be  most  easily  formed,  and 
will  give  the  micro-organisms  opportunity  for  forming  colonies  and  multiplying. 
On  the  other  hand,  wherever  the  water  at  the  svu-face  as  well  as  at  the  bottom  is 
in  a  state  of  rapid  motion,  and  subject  to  continuous  change,  these  conditions  are 
less  easy,  or  do  not  occur  at  all;  for  the  continuous  flow  of  the  water  prevents  the 
formation  of  a  local  concentration  of  nutritive  substances  in  the  liquid  sufficient  for 
pathogenic  bacteria.  The  connection  between  the  falling  of  subsoil  water  and 
the  increase  of  several  infectious  diseases  I  would  explain  as  follows.  That,  when 
the  subsoil  water  falls,  the  current  that  takes  place  in  the  subsoil  water  is  much 
less  significant.  Besides,  the  quantities  on  the  surface  are  much  diminished,  so 
that  those  concentrations,  which  I  assumed  to  be  necessary  for  the  growth  of  the 
bacteria,  must  much  sooner  take  place. 

If  we  assume  that  a  special  specific  organism  is  the  cause  of  cholera,  we  can- 
not think  of  an  autochthonous  origin  of  the  disease,  emanating  from  any  particu- 
lar locality.     Such  a  specific  organism,  even  if  it  be  only  a  comma-bacillus,  f oUows 


l(jg  ASIATIC  CHOLERA. 

the  laws  of  vegetation,  just  as  the  most  highly  developed  plant.  It  must  ahvaj^s 
propagate  itself  from  something  of  the  same  nature,  and  cannot  spring  up  at 
hap-hazard  from  other  things,  or  from  nothing.  But,  as  conmia-bacilli  do  not 
belong  to  micro-organisms  that  are  distributed  everywhere,  we  are  forced 
to  trace  back  the  disease  that  depends  upon  them  to  special  localities  from  which 
these  specific  micro-organisms  are  brought  to  us.  We  cannot,  therefore,  imagine 
that,  because  the  delta  of  the  Nile  i-esembles  the  delta  of  the  Ganges  in  some 
points,  cliolera  could  spontaneously  spi'ing  up  tiiere  by  way  of  exception,  as  was 
seriously  maintained  last  year.  Just  as  little  reason  have  we  for  supposing  that 
cholera  should  spring-  up  here  in  Europe  without  the  comma-bacillus  having  been 
previously  introduced. 

Koch  then  describes  the  peculiarities  of  the  endemic  home  of  cholera  in  India, 
adding  that  one  can  easily  imagine  what  quantities  of  vegetable  and  animal  mat- 
ter are  exposed  to  putrefaction  in  the  boggy  district  of  the  Sunderbunds,  and  that 
an  opportunity,  scarcely  to  be  found  in  any  other  i)lace  in  the  world,  is  offered 
here  for  the  development  of  micro-organisms.  In  this  respect,  the  boundary  be- 
tween the  inhabited  and  uninhabited  part  of  the  delta  is  especially  favorable. 
There  the  refuse  from  an  exceptionally  thickly  populated  country  is  floated  down 
by  the  small  streams,  and  mixes  with  the  brackish  water  of  the  Sundei'bunds  that 
flows  backward  and  forward,  and  is  already  saturated  with  putrefied  matter. 
Under  peculiar  circumstances  a  thorougiily  special  fauna  and  flora  of  micro-organ- 
isms must  develop  here,  to  which  in  all  probability  the  comma-bacillus  belongs. 

Koch  then  proceeds  to  show  that  the  comma-bacillus  finds  in  the  nature  of  the 
territory  described,  in  tin;  climate,  in  the  manner  of  native  hut-building,  and  in 
the  habits  of  the  people,  so  many  factors  that  favor  its  permanent  habitat  in  that 
part  of  India.  He  then  alludes  to  the  good  effects  of  sanitation  and  especially  the 
improvement  of  the  water  by  the  establishment  of  drains  and  similar  hygienic 
measures. 

As  a  good  illustration  he  describes  the  condition  of  things  in  Calcutta  befoi'e 
and  after  the  time  of  the  establishment  of  water-works.  But  the  influence  of  ob- 
taining good  water,  he  finds,  has  been  more  plainly  shown  at  Fort  William,  where 
cholera  ciisappeared  altogether  after  the  garrison  received  a  reliable  water  supply. 

On  the  other  hand,  Koch  distinctly  states  that  he  is  not  a  supporter  of  the  ex- 
clusive drinking-water  theory.  The  ways  in  which  cholera  can  spread  in  a  gtven 
locality  are  extremely  diverse.  He  holds  that  every  place  has  its  own  peculiar 
conditions,  which  must  be  carefully  studied  and  protective  measures  instituted  in 
accordance  therewith.  In  India  the  spread  of  cholera  cleai'lj-  depends  upon  human 
intercoui'se,  the  pilgrimages  being  largely  responsible  for  its  wide  dissemination. 

Regarding  cholera  on  ships,  he  points  out  that  real  epidemics  only  take  place 
when  a  large  numl)er  of  people  are  on  board. 

On  one  question  of  cholera  etiology,  which  is  of  a  more  theoretical  interest, 
I  have  not  yet  had  an  opportunity  of  saying  anything.  It  is  a  noteworthy  fact, 
that  outside  of  Inilia  cholera  always  dies  out  after  a  comparatively  sliort  space 
of  time.  This  disappearance  of  the  plague  seems  to  me  to  be  due  to  a  variety 
of  factore. 

In  the  fii-st  place,  I  consider  it  established  that  the  individual,  as  in  many  other 
infectious  diseases,  after  having  once  had  cholera,  acquires  a  certain  immunity. 
This  immunity  does  not  seem  to  be  of  very  long  duration,  for  we  have  examples 
enough  that  a  man  who  was  attacked  during  an  epidemic  cauglit  the  cholera 
again  in  a  second  epidemic;  but  one  seldom  hears  of  a  man  being  attacked  twice 
during  the  same  epidemic.  Bat  precisely  in  cholera  several  attacks  ought  to 
occur,  because  a  man  wlio  has  got  over  the  attack,  as  a  ride,  retiu-ns  after  a  few 
days  to  the  same  conditions,  and  exposes  himself  to  the  same  dangers  and  the 
same  source  of  infection.  Some  experiences  made  in  India,  moreover,  are  in 
favor  of  the  view  that  a  certain  immunity  is  obtained  after  recovery  from  an 
attack  of  cliolera.  In  the  same  manner  as  an  individual  can  obtain  immunity,  so 
can  whole  localities,  as  a  good  deal  of  experience  proves,  become  more  or  less  free 
from  cholera  for  a  certain  period.  It  is  often  seen  that  when  a  place  has  been 
attacked  by  cholera,  and  been  thorougiily  infected  by  it,  this  place  is  spared  the 
next  year,  or  it  only  suffers  slightly  when  the  cholera  returns. 

As  a  second  reason  for  the  extinction  of  a  cholera  epidemic,  we  must  take  the 
absence  of  a  permanent  state,  capable  of  assisting  the  infectious  material  in  sur- 
viving the  period  of  the  immunity  of  the  population  that  is  unfavorable  to  its 
development. 

Finally,  we  must  take  note  of  the  circumstance  that  tempei'atures  under  62.6'' 


THE  DOCTRINE  OF  KOCH.  I(j9 

Fahr.  have  such  an  unfavorable  effect  on  tlie  gTO\^  th  of  the  'baciUi  outside  the 
body,  that  their  multiplication  can  no  longer  take  place.  "When  all  these  factoi-s 
work  together:  wlien  winter  conies  on,  and  only  a  population  remains  which  is 
more  or  less  non-liable  to  the  epidemic,  then  it  must  die  out,  as  the  infectious 
matter  jiossesses  no  permanent  state. 

Before  I  conclude,  I  should  like  to  add  a  few  words  as  to  how  we  can  utilize 
the  discovery  of  the  comma-bacilli.  The  cry  we  commonly  hear  is — Yes,  but  what 
is  the  use  of  this  discovery  to  us?  We  certainly  know  that  the  cholera  is  caused 
by  comma-bacilli,  but,  nevei'theless,  we  are  in  no  better  position  for  curing  this 
disease  than  before.  I  remember  that  these  were  often  the  expressions  used 
about  the  discovery  of  tubercle-bacilli. 

Anybody  who  looks  upon  these  mattere  from  the  point  of  view  of  the  medical 
man  who  has  to  write  a  prescription,  is  certainly  rigiit  in  saying  tliat  he  has  as 
yet  no  perceptible  utility  before  him:  but  tliese  critics  ought  to  consider  that  ra- 
tional therapeutics  for  the  majority  of  diseases,  and  especially  for  infectious 
diseases,  cannot  be  obtained  till  we  have  found  out  their  causes  and  natui'e.  But, 
apart  from  this,  I  imagine  we  already  have  a  very  considerable  advantage  from 
tiie  discovery  of  the  comma-bacillus.  I  think,  first,  of  how  we  can  utilize  it  in  a 
diagnostic  direction.  It  is  highly  important  that  a  correct  diagnosis  should  be 
taken  of  the  first  cases  which  occur  in  a  country  or  locality.  According  to  my 
view,  by  showing  the  presence  or  absence  of  cholera-bacilli,  we  can  say  with  cer- 
tainty whether  we  have  cholera  before  us  or  not.  This  seems  to  me  to  be  a  veiy 
essential  advantage. 

I  further  think  that,  after  haAing  become  acquainted  with  the  real  cause  of  the 
disease  and  its  qualities,  the  etiology  of  cholera  can  be  constructed  on  detinite  and 
fixed  lines,  and  that  we  shall  at  length  get  rid  of  many  contradictions.  We  shall 
now  obtain  a  firm  basis  for  a  uniform  action  that  knows  the  end  at  which  it  is 
aiming.  I  anticipate  special  advantages  from  the  observation  tliat  comma-bacilli 
are  killed  by  being  dried. 

But,  above  all.  we  can  deduce  this  advantage,  that  an  end  will  at  length  be 
yjut  to  the  fearful  squandering  of  disinfectants,  and  that  millions  will  not  again, 
as  in  the  last  epidemics,  be  poured  into  gaitters  and  cesspools  without  the  slightest 
advantage. 

For  the  rest,  I  hope  that  the  recognition  of  the  comma-bacilli  can  be  turned  to 
account  therapeutically.  We  shall  be  able  in  future,  even  in  the  less  severe  cases, 
and  in  the  fii*st  stages,  to  make  a  diagnosis.  In  accordance  with  this,  therapeutic 
experiments,  also,  will  have  more  certainty  when  it  is  known  that  the  patient  is 
really  suffering  from  cholera.  An  early  diagnosis  must,  however,  be  of  all  the 
greater  value,  as  the  chance  of  therapeutic  success  is  precisely  greatest  in  the  fii-st 
stages. 

It  is  beyond  the  scope  of  this  vohime  to  give  a  detailed  account  of  the 
interesting  and  important  discussion  that  followed  the  reading  of  Koch's 
elaborate  address.  But  in  order  to  indicate  its  nature  and  acquaint  the 
reader  with  the  general  drift  of  opinion  elicited  during  the  debate,  the 
questions  submitted  for  consideration  by  Koch  are  here  reproduced  with 
this  comment,  that  the  answers,  in  the  main,  fully  harmonized  with 
Koch's  personal  vie^ys. 

The  questions  discussed  were  the  following: 

Is  cholei-a  caused  by  an  infectious  material,  originating  only  in  India  ? 

Is  the  iafectious  material  contained  only  in  the  dejections,  and  later  also  in 
the  vomited  matters,  or  is  it  found  also  in  the  blood,  urine,  sweat  and  breath  'i 

Has  the  finding  of  comma-bacilli  any  diagnostic  importance? 

Is  the  infectious  material  of  cliolera  identical  with  the  comma-bacilli  ? 

Has  this  infectious  material  much  power  of  resistance  and  a  condition  of  per- 
manency?   And  is  it  destroyed  in  a  short  time  by  drying? 

Can  the  infectious  material  enter  the  body  tlirough  any  other  channels  than 
the  digestive  tract  ? 

Is  the  infectious  material  reproduced  within  the  body,  or  does  this  occur  in  the 
ground,  man  and  animals  merely  acting  as  carriers? 

Is  a  direct  transplantation  possible,  or  must  the  infectious  material  undergo 
some  sort  of  ripening  or  modification  in  the  ground  or  elsewhere  ? 

Is  a  special  individual  predisposition  necessary  for  the  action  of  the  infectious 
material?  What  is  the  duration  of  the  period  "of  incubation?  Does  one  attack 
•c-onfer  immunity  for  a  certain  length  of  time?  Can  the  modus  operandi  of  the 
bacilli  be  interpreted  as  an  intoxication? 


170  ASIATIC  CHOLERA. 


CHAPTEK  XXII. 

OTHER  RECENT  RESEARCHES  ON  CHOLERA. 

Having  presented  an  accnrate  and  complete  statement  of  Koclrs  doc- 
trine in  the  last  chapter,  we  may  now  profitably  turn  our  attention  to  the 
recent  investigations  into  the  nature  of  cholera  carried  on  by  others,  Avork- 
ing  independently  of  the  German  inquirer. 

An  examination  of  these  recent  researches  will,  among  other  thiiigs, 
serve  to  bring  out  the  controversial  issues  raised  since  the  announcement 
of  his  doctrine  by  Koch.  Mere  polemics  will  be  avoided  as  much  as  pos- 
sible. The  arguments  of  those  who  completely  oppose  Koch  will,  of  course, 
receive  the  same  impartial  consideration  extended  to  the  views  of  the 
writers  who  uphold  him. 

During  the  epidemic  at  Toulon,  Straus  and  Roux  continued  certain 
researches,  begun  in  1883  in  Egypt  together  with  Thuillier  and  Nocard. 
In  their  report  to  the  Paris  Academy  of  Medicine  they  say  that  they  do 
not  believe  Koch's  comma-bacillus  to  be  the  specific  microbe  of  Asiatic 
cholera.     It  has,  they  assert, 

been  observed  in  other  diseases,  and  cholera  has  not  been  provoked  in  animals 
by  inoculations  of  this  baciUus.  Dr.  Straus  maintained  that  the  researches  made 
at  Toulon  confirmed  the  results  of  those  made  in  Egypt.  There  they  detected  the 
presence  of  micro-org-anisms  in  the  intestinal  mucous  membrane,  especially  when 
the  attack  was  prolonged,  and  the  intestines  jiresented  minute  patches  of  hemor- 
rhage. In  three  cases  of  cholera  where  the  patients  were  struck  down  in  ten  or 
twenty  hours,  the  intestines  at  the  autopsy  were  found  not  congested.  On  the 
contrary  they  were  paler  than  norinal.  It  was  also  impossible  to  detect  the 
presence  of  a  micro-organism.  In  another,  a  very  severe  case,  it  was  necessary  to 
make  a  considerable  number  of  preparations  in  order  to  find  a  few  bacilli.  Some 
of  the  sections,  colored  bj^  methyl  blue,  made  from  fragments  of  the  small  intes- 
tines, which  were  pi-eviously  hardened  in  alcohol,  exliibited  mici'o-organisms  in 
the  superficial  parts  of  the  mucous  membrane  of  the  ducts  of  the  tubular  glands, 
and  in  the  basement  membrane  of  the  villi.  These  micro-organisms  vai-ied  in 
number  according  to  the  time  the  attack  had  lasted.  Bacilli  were  more  abundant 
tiian  other  organisms.  They  varied  greatly,  both  in  aspect  and  in  dimension. 
Some  were  long  and  thin,  others  short  and  broad.  The  varietj'  most  frequently 
observed  resembled  the  bacillus  of  tuberculosis.  In  some  parts  this  bacillus  pi'e- 
dominated,  and  penetrated  as  far  as  the  submucous  membrane,  but  never  entered 
the  blood-vessels  nor  the  muscular  coat  of  the  intestines.  Other  f oi'ms  of  bacilli 
and  mici'ococci  were  also  present  in  the  substance  of  the  mucous  membrane. 
This  entei-o-mycosis  was  especially  evident  in  the  lower  portion  of  the  small  intes- 
tine. Straus  and  his  colleagues  did  not  consider  that  these  data  furnished  con- 
clusive  evidence   concerning  the   origin  of  cholera. 

Straus  also  draws  attention  to  the  fact  that,  during  life,  the  intestinal 
mucous  membrane  of  cholera  patients  loses  its  epithelium,  and  therefore 
may  be  easily  invaded  bj^  the  organisms  present  in  the  surrounding  fluids. 
He  suggests  a  secondary  invasion  of  the  intestine  by  microbes.  Straus  and 
Roux    state   further  that  the  rice-water   stools   of    cholera  patients  also    con- 


OTHER  RECENT  RESEARCHES.  IJl 

tain  micro-organisms.  Among  these  the  comma-  form  is  frequently  seen.  Tliis 
micro-organism  is  found  almost  isolated  in  the  intestinal  mucus.  They 
do  not  consider  that  proof  of  its  specificity  is  obtained  until  cholera  is  pro- 
voked in  animals  inoculated  with  a  perfectly  pure  cultivation.  Moreover,  the 
comma-bacillis  is  not  special  to  cholera.  Dr.  Maddox,  of  London,  has  photo- 
graphed a  micro-organism  found  in  a  water  cistern,  presenting  the  form  of  a 
comma.  Malassez  has  detected  it  in  the  stools  of  dysenteric  patients,  among  many 
other  varieties.  Straus  and  Roux  also  observed  it  in  the  vaginal  mucus  of 
women  suffering  from  leucorrhoea,  and  in  the  uterine  secretion  of  a  woman  affected 
with  epitheliomxa  of  the  cervix  uteri.  In  their  report  on  the  cholera  epidemic  in 
Egj'^pt,  the  authors  indicated  in  the  blood  of  cholera  patients  the  presence  of  ex- 
cessively small,  thin  particles,  presenting  the  aspect  of  oi'ganisms.  At  Toulon,  the 
same  phenomena  were  observed  in  the  course  of  their  researches,  though  not 
always.  They  supposed  these  corpuscles  to  be  due  to  a  special  alteration  of 
haemoglobin. 

It  will  be  remembered  that  Kocli  in  his  address  alluded  to  this  matter, 
saying  that  Straus  had  been  unable  to  demonstrate  to  him  the  alleged  organ- 
isms of  cholera  blood. ' 

The  Marseilles  epidemic  of  last  year  naturally  became  the  occasion  of 
much  medical  research,  directed  toward  the  elucidation  of  various  cholera 
problems. 

The  first  investigators  to  publish  an  account  of  their  doings  were  M. 
Magnon,  Professor  of  Natural  Sciences  at  the  Lyceum,  and  M.  Cognard, 
who  was  delegated  by  the  Medical  Society  of  Lyons  to  study  on  the  spot 
the  disease  in  all  its  bearings.  ^  These  gentlemen  directed  their  researches 
especially  to  the  question  of  the  transmissibility  of  cholera  from  man  to 
the  lower  animals.  In  order  to  render  their  experiments  as  conclusive  as 
possible  they  employed  various  modes  of  procedure  and  made  use  of  several 
different  varieties  of  animals.  But  in  no  case  was  any  positive  result 
obtained.  In  a  preliminary  report  made  by  M.  Cognard  prior  to  his  de- 
parture from  Marseilles,  he  stated  that  the  experiments  were  undertaken 
from  a  conviction  that  the  only  means  of  arriving  at  any  positive  conclusions 
concerning  the  infectious  agent  of  cholera,  which  might  serve  as  a  basis 
for  a  rational  therapy,  was  by  inoculating  the  lower  animals.  With  this 
object  they  injected  into  the  veins  filtered  choleraic  discharges  and  also 
atmospheric  water  from  the  wards  of  the  Pharo  hospital,  obtained  from 
the  moisture  collecting  in  the  sides  of  a  jar  filled  with  cold  water.  They 
likewise  injected  a  Pravaz  syringeful  of  cholera  dejections  containing  mi- 
crobes, especially  comma-bacilli,  into  the  trachea  of  a  monkey  and  into  the 
cellular  tissues  of  a  cat.  But  their  most  common  mode  of  procedure,  and 
one  which  they  claim  they  were  the  first  to  employ,  was  to  expose  a  loop 
of  the  small  intestine  through  an  incision  made  in  the  linea  alba,  and,  after 
incising  this,  to  inject  a  large  syringeful  of  the  cholera  dejections.  The  in- 
testine was  then  sutured  and  returned  into  the  abdominal  cavity  and  finally 
the  external  wound  was  closed.  The  animals  experimented  upon  were 
cats,  monkeys,  a  dog,  a  large  white  rat  and  a  jackal,  Not  one  of  them 
died  of  cholera.  Only  two  of  the  animals  died,  death  in  both  instances 
being  due  to  peritonitis  and  not  cholera.  Magnon  and  Cognard  concluded, 
therefore,  that  for  this  epidemic  at  least,  the  lower  animals  were  not  sus- 
ceptible to  the  action  of  the  cholera  poison.  ^ 

The  reader  is  also  referred  to  the  section  on  Morbid  Anatomy,  where  will  be 
found  a  quite  recent  retraction  by  Straus  of  the  claim  concerning  the  occurrence 
of  micro-organisms  in  the  blood  of  cholera  patients. 

-  Etude  historique  et  pratique  sur  la  prophylaxie  et  le  traitement  du  cholera. 
Par  le  Dr.  H.  Mireur,  Paris  and  Marseilles,  1884. 

^  Repeated  attempts  have  been  made  3'ears  ago  by  Thiersch  and  others,  to  cause 


]72  ASIATIC  CHOLERA. 

The  National  Medical  Society  of  Marseilles  appointed  a  commission  to 
study  the  cholera  during  the  epidemic  of  1884,  consisting  of  MM.  A. 
Sicard,  Taxis,  Bouisson,  Queirel,  Poucel,  Livon  and  Chareyre.  In  their 
official  report '  they  deem  it  necessary  to  state  that  their  investigations 
were  begun  Avithout  prejudice  or  inclination  to  any  particular  theory. 
There  were  two  views  which  demanded  their  special  attention  by  reason 
of  the  high  reputation  and  the  scientific  attainments  of  their  respective 
French  and  German  upholders.  For  this  reason  they  devoted  their  time 
chiefly  to  the  study  and  examination  of  the  intestinal  contents  and  of  the 
blood.  The  first  thing  that  attracted  their  attention  was  that  there  Avas 
always  an  inverse  relation  between  the  number  of  comma-bacilli  and  the 
degree  of  coloration  of  the  stools,  the  rice-water  discharges  containing 
the  microbes  in  greatest  abundance.  Every  conceivable  elfort  Avas  made 
to  transmit  cholera  to  the  lower  animals,  vomited  matters  and  the  intes- 
tinal contents,  filtered  and  not  filtered,  were  injected  in  A'arious  Avays  into 
the  trachea,  stomach,  small  and  large  intestine,  peritoneal  cavity,  and 
blood- A'essels,  but  in  no  case  were  any  signs,  either  clinical  or  pathological,' 
of  cholera  observed.  Yet  in  a  rabbit,  dying  eleven  days  after  such  an  in- 
jection into  the  small  intestine,  Avithout  a  sign  of  cholera,  numbers  of 
comma-bacilli  Avere  found  in  the  gut,  shoAving  that  the  soil  Avas  at  least 
favorable  to  their  preserA^ation.  The  injection  of  fresh  matters  having 
failed,  a  rice-Avater  stool,  consisting  of  almost  a  pure  culture  of  the  com- 
ma-bacillus, Avas  obtained.  Some  pieces  of  linen  Avere  noAv  soaked  in  this 
fluid  and  preserved  moist  for  some  time.  Inoculations  made  Avith  the 
washings  of  these  rags,  at  the  end  of  three  and  again  of  nine  days,  gave 
negative  results.  The  animals  used  in  these  experiments  Avere  rabbits, 
dogs  and  guinea-pigs. 

As  Koch  had  stated  that  water  was  liable  to  contamination  byiihe 
cholera  bacilli,  an  examination  was  made  of  Avater  taken  from  a  faucet  in 
their  laboratory  and  from  the  Rose  near  its  source.  For  its  examination 
they  used  the  method  described  by  Koch,  and  found  that  the  water  taken 
from  the  Rose  contained  on  an  average  ten  comma-bacilli  in  every  drop 
or  250,000  in  every  litre.  A  poAver  of  COO  diameters  was  used,  and  the 
bacilli  found  Avere  identical  in  size,  appearance  and  mode  of  staining  with 
those  described  by  Koch. 

The  investigators  next  turned  their  attention  to  the  blood,  and  first  to 
the  bodies  described  by  Straus.  But  they  soon  found  that  these  little 
bodies  Avere  present  in  healthy  individuals  as  Avell  as  in  the  sick.  Other 
A-arieties  of  micro-organisms  Avere  found  in  the  circulating  fluid,  but 
none  Avhich  by  their  constancy  could  be  regarded  as  characteristic.  They 
found,  hoAvever,  an  alteration  in  the  red  blood-corpuscles  Avhich  they 
regarded  as  of  great  importance.  The  change  did  not  affect  all  the  glob- 
ules at  once,  for  often  corpuscles  profoundly  altered  Avere  seen  by  the 

cholera  in  the  lower  animals,  either  by  feeding  them  with  matter  passed  from 
the  bowel  or  A^omited  by  cholera  patients.  They  liave  been  quite  recently 
repeated,  and  additional  "experiments  have  been  instituted  by  injecting  pure 
cultures  into  the  veins  or  subcutaneously.  But  most  of  these  experiments  liaA-^e 
been  entirely  Avitliout  result.  Such  inoculations,  in  order  to  be  successful,  must 
be  practiced'  upon  animals  Avhich  are  susceptible  to  the  poison  of  cholera.  It  Avas 
formerly  belie\-ed  that  many  species  of  animals  were  subject  to  attacks  of  Asiatic 
cholera,  but  modern  veterinarians  have  denied  that  this  is  the  case.  See  also  the 
accovmt  of  Van  Ermengem's  most  recent  investigations,  which  invariably  gaA'e 
positive  results  Avhen  guinea-pigs  were  employed. 

'  Recherches  sur  le  cholera.  Rapport  lu  au  nom  de  la  Commission,  etc.  Mar- 
seilles, 1884. 


OTHER  RECENT  RESEARCHES.  173 

side  of  perfectly  healthy  ones.  This  alteration,  they  stated,  consists  in  a 
softening  of  the"  corpuscles,  whence  results  a  change  of  shape  from  mutual 
pressure,  and  an  agglutination  of  numbers  of  the  globules  in  masses  of 
greater  size  as  the  disease  is  more  advanced.  If  a  current  becomes  estab- 
lished in  the  field  of  observation,  these  diseased  globules  are  seen  flowing 
along  like  lava  or  melted  tar  between  the  more  compact  masses.  Some- 
times the  corpuscles  are  seen  to  become  elongated,  olive-shaped,  or  even 
almost  cylindrical  through  the  action  of  the  current;  sometimes  they  are 
torn  away  from  the  mass,  and  then  owing  to  their  elasticity  tliey  frequently 
return  to  their  normal  shape.  But  in  the  gi-aver  cases  of  the  disease  the 
corpuscles  seem  to  have  lost  this  elasticity  and  maintain  their  oval  shape 
even  when  entirely  separated  from  the  neighboring  corpuscles.  If  artifi- 
cial serum  be  added  during  the  microscopical  examination,  most  of  the 
red  globules  may  be  seen  to  resume  their  proper  shape,  to  become  de- 
tached from  the  sticky  mass,  and  to  arrange  themselves  in  the  normal  way 
like  rolls  of  coin;  but  where  the  alterations  are  most  profound  this  sepa- 
ration does  not  occur.  This  change  in  the  blood  Avas  found  in  every  case, 
and  the  commission  stated  that  they  were  disposed  to  regard  it  as  charac- 
teristic, as  "the  pathognomonic  lesion  of  cholera." 

Several  experiments  were  undertaken  to  determine  the  power  of  this 
altered  blood  to  transmit  cholera  to  the  lower  animals,  but  they  were  not 
conclusive.  Two  rabbits,  upon  which  injections  were  practiced  with 
blood  taken  from  a  subject  dead  at  the  beginning  of  the  algid  stage,  died 
at  the  expiration  of  eighteen  hours,  presenting  lesions  "which  we  should 
be  inclined  to  regard  as  belonging  to  cholera "  and  the  htematic  changes 
above  described.  Two  other  rabbits  injected  with  blood  taken  from  a 
living  subject  at  the  beginning  of  the  cold  stage  had  diarrhoea  with  colored 
stools  the  following  day,  and  in  one  of  them  there  were  seen  masses  of 
agglutinated  red  blood-globules.  A  dog  injected  with  blood  taken  from 
a  subject  dead  in  the  algid  stage  suffered  for  two  days  from  a  serous  diar- 
rhoea. All  the  remaining  experiments,  to  the  number  of  twenty-five, 
made  with  blood  taken  during  a  prolonged  algid  stage  or  in  the  period  of 
reaction,  gave  negative  results.  The  blood  used  in  the  first  experiment, 
kept  at  a  temperature  of  100"  F.  in  air  filtered  through  cotton,  speedily 
lost  its  virulence. 

The  conclusions  drawn  by  this  commission  from  their  researches  were 
that:  1.  Cholera  may  be  transmitted  to  the  lower  animals;  2.  The  con- 
tents of  the  stomach  "and  intestines  and  even  the  pure  rice-water  discharges 
are  absolutely  inoffensive;  3.  The  same  is  true  of  blood  taken  during  the 
period  of  reaction,  and  it  is  only  in  the  algid  stage  that  it  possesses  an  in- 
fectious property;  4.  This  property  is  the  more  marked  the  nearer  to  the 
beginning  of  the  cold  stage  the  blood  is  taken;  and  it  disappears  within, 
at  the  most,  twenty-fourhours  after  the  blood  is  drawn,  and  probably  in 
a  much  shorter  time.  They  state  further  that  their  investigations  force 
them  to  regard  the  German  theory  as  merely  an  hypothesis  Avhicli  is  not 
supported  by  a  single  experiment  and  which  receives  a  ncAv  refutation  in 
the  mode  of  jiroimgation  of  cholera.  They  confessed,  however,  that 
although  "  we  have  shown  the  toxic  action  of  the  blood  in  the  algid  stage, 
we  have  been  unable  to  discover  in  it  any  specific  agent." 

They  likcAvise  are  forced  to  admit  that  the  result  of  their  investigations 
enables  them  to  say  "Avhat  cholera  is  not,  rather  than  what  cholera  is." 

We  come  next  to  a  communication  made  to  the  Semaine  Medicale '  by 

1  Senuune  Medicale,  No.  38,  1884. 


174 


ASIATIC  CHOLERA, 


Drs.  Nicati  and  Eietscli  in  which  they  give  a  resume  of  the  experiments 
conducted  by  them  up  to  that  time.  They  state  that  when  the  intestinal 
contents  of  a  person  dead  of  cholera,  or  an  artificial  culture  of  comma- 
bacilli,  is  injected  into  the  duodenum  of  a  dog,  after  ligature  of  the  ductus 
choledochus,  the  animal  dies  after  one  or  several  days,  and  its  intestine, 
like  that  of  a  person  dying  after  suffering  from  cholera  for  some  hours,  is 
found  filled  with  a  thick  milky  fluid  very  rich  in  epithelial  cells.  The  comma- 
bacilli  are  found  there  in  abundance  after  the  material  has  been  exposed 
to  moist  air  for  a  length  of  time  varying  with  the  temperature.  It  has 
been  objected  that  the  ligature  of  the  common  duct  is  alone  sufficient  to 
cause  death,  but  the  authors  assert  that  even  when  this  happens  it  does 
not  by  any  means  rapidly  follow  the  operation.  Cats  have  survived  the 
operation  from  one  to  nineteen  days,  and  guinea-pigs  from  three  to  twenty- 
eight  days.  These  animals  at  one  commence  to  eat  and  soon  regain  their 
usual  strength.  It  is  only  some  days  afterward  that  they  begin  to  ema- 
ciate, and  they  finally  die  after  having  lost  considerable  weight.  The 
same  lesions  as  those  observed  in  the  dogs  were  seen  in  guinea-pigs,  after 
an  injection  into  the  duodenum  without  previous  ligature  of  the  choledoch 
duct,  and  even  after  the  introduction  of  a  large  quantity  of  the  virulent 
material  into  the  stomach  by  means  of  a  catheter.  The  symptoms  observed 
during  life  were  diarrhoea,  vomiting  (only  in  dogs),  cyanosis  and  reduction 
of  temperature.  In  one  instance  an  increase  of  temperature  was  observed 
in  a  dog  after  death.  An  examination  of  the  blood,  as  in  cholera  patients 
in  the  algid  stage,  showed  no  tendency  in  the  red  globules  to  become  cre- 
nated,  but,  on  the  contrary,  they  became  altered  in  shape  by  mutual  pres- 
sure, as  occurs  when  asphyxia  is  produced  by  mechanical  compression  of 
the  trachea. 

Starting  with  the  assumption  that  when  an  inoculation  was  without 
results  it  was  by  reason  of  digestion  of  the  ferment  by  the  gastric  or  intes- 
tinal secretions,  MM.  Nicati  and  Eietsch  made  a  study  of  these  various 
secretions.  They  found,  as  stated  by  Koch,  that  the  gastric  juice  was 
very  destructive  to  the  comma-bacilli.  The  pancreatic  juice  seemed  to 
be  Avithout  effect.  The  bile  also  appeared  to  exert  no  deleterious  influence 
upon  the  comma- bacilli  in  broth  cultures,  but  certain  facts  would  seem  to 
show  that  it  possessed  a  different  action  in  the  living  intestine.  In  ex- 
amining choleraic  dejections  they  found  several  specimens  in  which  the 
bacilli  were  exceedingly  abundant,  where  scarcely  a  trace  of  bile  could  be 
detected  by  the  nitric  acid  test. 

In  their  recently  published  monograph,'  MM.  Maurin  et  Lange 
claim  to  have  discovered  the  true  micro-organism  of  cholera.  It  is  a  fun- 
gus growth  consisting  of  mycelium,  filaments  and  sj)ores,  to  which  they 
have  given  the  name  of  Mncor  clioleriferus.  This  fungus  they  found  to  be 
developed  invariably  in  cholera  dejections,  after  standing  four  or  five  days, 
but  in  no  others.  The  spores,  they  state,  are  constantly  floating  in  the 
atmosphere  of  an  infected  district,  and  thence  gain  ready  access  to  the 
human  organism.  When  taken  into  a  healthy  stomach  they  are  difficult 
of  digestion  and  give  rise  to  a  painful  tension  of  this  organ,  so  commonly 
observed  during  an  epidemic  of  cholera.  But  if  indigestion  be  present 
and  the  stomach  contain  acescent  or  putrescent  matters,  the  spores  germi- 
nate and  produce  long  chains.  This  is  similar  to  what  occurs  when  mucor 
racemosus  attacks  acid  wine.     These  chains  act  like  ferments  absorbing 

Mucor  Cholerifere,  Organisme  de  Transmission  du  Cholera.     Paris:  Felix  Alcan, 

1885. 


OTHER  RECENT  RESEARCHES. 


175 


oxygen,  water  and  heat,  and  to  their  vegetation  are  due  all  the  phenomena 
of  cholera. 

In  acetic  fermentation,  after  the  mycoderma  has  produced  its  effect, 
spirilla  make  their  appearance.  And  precisely  in  the  same  way  in  choleraic 
fermentation  after  the  chain  plants,  developed  from  the  spores  of  the 
mucor,  have  produced  their  effects,  the  vibrio  virgula  of  Pacini  (now 
better  known  under  the  name  of  Koch's  bacillus)  appears  upon  the  scene. 
But  the  comma-bacillus  is  not  the  cause  of  the  choleraic  fermentation;  it 
is  only  developed  secondarily  because  it  finds  there  a  favorable  soil.  That 
is  the  reason  why,  in  rapidly  fatal  cases  {cas  foudroi/anfs)  no  bacilli  are 
found.  "The  bacillus  of  Koch  is  an  epiphenomenon  of  the  choleraic 
fermentation."  The  organism  of  transmission  of  the  disease  is  indeed 
contained  in  the  intestine  of  the  cholera  patient,  but  in  order  to  become 
active  it  must  be  incubated  for  a  certain  length  of  time  in  the  open  air. 
That  is  why  cholera  is  not  immediately  contagious,  and  why  the  stools 
are  one  of  the  active  and  real  agents  of  the  secondary  contagion  which 
creates  ej)idemic  centers. 

Comment  upon  this  publication,  which  was  heralded  in  France  as  a 
great  discovery,  is  hardly  called  for.  The  plan  of  procedure  adopted  by 
Maurin  and  Lange  is  found  to  be  so  crude,  when  examined  in  the  light  of 
the  exact  experimental  methods  of  modern  inquiries,  that  it  is  unnecessarv 
to  further  emphasize  that  their  observations  are  certain  to  remain  sterile. 


176  ASIATIC  CHOLERA. 


CHAPTER   XXIII. 

THE  CHOLERA-BACILLUS   CONTROVERSY— KOCH'S  DISCOVERY 

CONFIRMED. 

The  investigations  described  in  the  last  chapter  indicate  a  laudable 
zeal  to  ascertain  the  nature  of  cholera,  and  have  in  a  measure  extended 
our  knowledge  of  the  disease,  Koch's  views,  it  was  seen,  were  by  no 
means  accepted  by  all  these  French  experimenters.  It  seems  proper 
in  the  next  place  to  briefly  refer  to  some  of  the  more  direct  criticisms 
called  forth  by  the  German's  announcement  of  the  discovery  of  the 
specific  microbe  of  cholera.  Now  in  the  opinion  of  the  editor  it  is  a 
rather  deplorable  fact  that  those  who  Avere  from  the  first  disinclined  to 
accept  Koch's  conclusions  have  busied  themselves  much  more  wdth  find- 
ing evidence  that  might  overthrow  his  doctrine,  than  with  j^i'osecuting 
independent  inquiries  calculated  to  shed  additional  light  on  the  obscure 
points  of  the  disease. 

Of  course  Koch  from  the  first  found  many  ardent  supporters.  But 
repeated  negation  on  one  side,  with  affirmation  and  reiteration  on  the 
other,  has  at  length  resulted  in  a  bitter  and  determined  cholera-bacillus 
war.  At  the  present  writing  the  contest  still  continues,  and  for  the  sake 
of  pure  science,  it  is  much  to  be  regretted  that  latterly  personal  and 
national  feelings  have  been  imported  into  the  strife. '  That  this  is  detri- 
mental to  the  advancement  of  scientific  knowledge  goes  without  saying. 

It  may  be  Avorth  while  to  remember  that  not  long  ago  we  were  in  the 
midst  of  a  tubercle-bacillus  war.  In  the  Medical  Press  and  Circular, 
December  31,  1884,  the  following  comment  tliereon  is  made  (with  more 
particular  reference  to  Allgemeine  Wiener  Med,  Zeitung), 

The  plan  of  attack  adopted  seems  mcainly  that  of  searching-  out  every  scientist 
or  pseudo-scientist  who  writes  against  Koch.  When  one  is  found  he  is  immedi- 
ately discovered  and  pronounced  to  be  a  great  authority,  before  whom  Koch  must 
of  necessity  lower  liis  colors.  It  will  easily  be  foreseen  that  a  warfare  such  as  this 
could  only  have  one  ending,  viz.,  tlie  entire  demolition  of  the  bacillus  and  its 
discoverer.  This  result  has  been  achieved  many  times,  and  yet,  curious  to  relate, 
nearlj^  all  the  leading  pathologists  in  Germany,  as  well  as  those  of  France  and 
our  own  country,  have  completely  accepted  Koch's  views  as  correct  and  have 
worked  on  them  for  a  considerable  period,  with  the  result  that  their  opinions 
as  to  their  correctness  have  been  strengthened. 

It  is  too  early  in  the  cholera-bacillus  war  now  to  predict  its  ending. 
But  all  impartial  witnesses  must  see  the  strength  of  Koch's  position.  As 
was  pointed  out  by   a   leading  medical  journal   in    a   recent    editorial 

'  See  for  example  the  ill-advised  and  intensely  personal  attack  of  Prof essor  Ray 
Lankester  upon  Koch,  published  in  the  Pall  Mall  Gazette,  for  October  6,  1884. 


THE  CHOLERA-BACILLUS  CONTROVERSY.         IJJ 

notice,  "  Koch's  doctrine  lias  the  great  advantage  of  being  positive,  plau- 
sible, aided  by  analogy  and  circumstantial  evidence,  and,  further,  sup- 
ported by  the  accumulating  evidence  of  independent  investigations. "' ' 

Now  we  have  no  intention  of  presenting  to  the  reader  a  detailed  account 
of  the  heated  controversy  concerning  the  signilicance  of  the  comma-bacillus. 
Xevertheless,  as  already  stated,  some  of  the  more  important  objections  to 
Koch's  views  will  have  to  occupy  our  attention,  on  account  of  the  wide 
currency  they  have  obtained,  and  because  it  is  supposed  by  some  that  the 
parasitic  doctrine  has  through  their  universal  acceptance  received  its  well- 
earned  death-blow.  Tlie  fact  that  most  of  the  French  observers  do  not 
admit  the  binding  force  of  Koch's  arguments  has  already  been  noticed. 

Among  English  writers  the  first  and  foremost  to  raise  objections  against 
the  acceptance  of  Koch's  bacillus  doctrine  was  Dr.  Lewis.  In  the  Lancet 
of  September  20th,  1884,  he  stated  that  comma-like  bacilli,  identical  in 
size,  form  and  in  their  reaction  with  aniline  dyes,  with  those  found  in 
choleraic  dejections,  were  ordinarily  present  in  the  mouth  of  perfectly 
healthy  persons. " 

At  the  annual  meeting  for  1884,  of  the  Association  of  German  Natural- 
ists and  Physicians,  a  communication  was  made  Ijy  Prof.  Finkler  and  Dr. 
Prior,  of  Bonn,  to  tbe  effect  that  they  had  found  in  cholera  nostras  a  micro- 
organism whose  shape  was  identical  with  that  of  the  comma-bacillus  of 
Asiatic  cholera.  Its  biological  qualities,  when  cultivated,  were  regarded 
as  absolutely  the  same  as  those  of  the  comma-bacillus  described  by  Koch. 
They  claimed  to  have  discovered  evidence  of  a  spore-formation  in  the 
comma-bacilli  of  cholera  nostras  which  had  not  been  established  in  like 
manner  for  the  bacilli  of  Asiatic  cholera.  Klamann  stated  at  the  same 
meeting  that  he  also  had  found  in  cholera  nostras  organisms  exactly  like 
those  shown.  The  statements  of  Finkler  and  Prior  were,  however,  criticised 
on  the  spot  by  Hueppe,  formerly  a  worker  in  Koch's  laboratory.  lie  called 
attention  to  the  differences  in  the  appearance  of  the  comma-bacilli  of 
Koch  and  of  those  shown  by  Finkler  and  Prior.  He  also  said  that  the 
cultivations  of  these  observers  were  probably  impure,  as  their  statements 
concerning  the  development  of  the  bacilli  did  not  at  all  harmonize  Avith 
those  of  Koch,  whose  investigations  had  continued  over  a  much  longer 
period  of  time. 

Koch's  reply  to  these,  the  most  important  criticisms  that  had  appeared 
until  that  time,  was  published  on  November  6th,  in  the  Deutsche  Medi- 
cinische  Wochenschrift. 

It  is  unnecessary  here  to  follow  him  in  his  demonstration  of  the  errors 
into  which  the  above  observers  had  fallen.  Suffice  it  to  say  that  not  by  the 
weight  of  authority,  but  from  the  stress  of  facts,  his  position  was  pretty 
generally  recognized  to  be  stronger  than  ever. 

>  The  Medical  Record,  February  28,  1885. 

•2  In  the  Deutsche  Med.  Wochenschrift  (November  27,  1884),  W.  D.  Miller 
claims  that  in  1882  he  described  tiie  curved  bacilli  in  the  buccal  mucus  to  which 
Dr.  Lewis  has  drawn  attention  as  identical  witli  the  comma-bacillus.  He 
also  contribvites  furtlier  particulars  concerning-  the  various  bacterial  organisms 
foimd  in  this  region  and  in  the  alimentary  canal.  The  curved  bacilli  and  spiro- 
chaete  forms  he  has  been  unable  to  cultivate  in  various  media,  and  thei'efore  tiiey 
do  not  resemble  in  all  respects  tlie  comma-bacillus.  Another  organism  is  one 
which  occui-s  in  the  form  of  short  plump  rods,  often  in  pairs,  and  it  gi'ows  rapidly 
in  gelatine.  Another  variety  is  ciu'ved,  and  by  the  conjunction  of  two  or  more 
inchviduals  pi-oduces  S-shaped  or  circular  forms.  This  organism  never  produces 
spores,  and  grows  very  slowly  in  gelatine. 
12 


178 


ASIATIC   CHOLERA. 


Tiiko  for  a  single  example  the  following  editorial  comment  from  the 
Philadelphia  Medical  Xews,  of  November  29th,  1884: 

Koch  has  two  great  qualities  as  an  investigator — unequaled  technique  and 
powers  of  patient  observation.  His  experience  has  been  vast,  and  each  piece  of 
work  wliich  he  has  done  has  been  remarkable  in  leaving  but  little  to  cori'ect, 
either  by  himself  or  by  subsequent  observer.  No  Avriter  on  mycology  is  more 
reliable;'  not  one  has  proved  himself  worthier  of  professional  confidence. 

And  again, 

These  latest  observations  of  Koch  afford  additional  strong  confirmatorj'-  e%i- 
dence  of  the  correctness  or  his  views  concerning  the  etiology  of  cholera  and  its 
connection  with  the  comma-bacillus. 

In  this  connection  allusion  must  also  be  made  to  the  conclusions  of 
Ceci  and  Klebs,  who  studied  cholera  at  Genoa.  In  a  preliminary  report ' 
these  authors  formulated  twelve  propositions,  the  pith  of  which  amounts 
to  the  assertion  that  the  commas  and  spirilla  of  Asiatic  cholera  looked  pre- 
cisely like  those  found  by  Prior  and  Finkler  in  cholera  nostras.  Klebs 
also  claimed  to  have  discovered  commas  in  the  diarrhoeal  discharges  of  a 
patient  having  pneumonia. 

But  in  a  more  recent  publication  by  Klebs, ^  he  admits  that  a  differential 
diagnosis  between  Asiatic  and  simple  cholera  is  possible  by  the  aid  of 
Koch's  comma-bacillus.  But  he  does  not  believe  that  it  is  always  an  easy 
matter  to  differentiate  between  the  two.  For  the  positive  recognition  of 
cholera  spirilla,  he  asserts  that  the  culture  method  is  indispensable. 

And  Ceci,  after  more  extended  experimental  experience,  has  even  come 
to  the  conclusion  that  the  comma-bacilli  of  Koch  are  positively  causative 
of  cholera.^  His  injections  of  pure  cultures  into  the  intestines  of  guinea- 
pigs  invariably  killed  those  animals  after  symptoms  of  true  cholera  had  been 
observed.  Post-mortem  examinations  showed  characteristic  lesions,  and 
in  the  rice-water  contents  of  the  intestines  countless  commas  were  found. 
Ceci  is  of  opinion  that  the  symptoms  of  cholera  are  of  reflex  nervous  origin, 
the  primary  irritation  being  produced  by  mechanical  or  chemical  action 
of  the  bacilli  in  the  intestines. 

In  place  of  giving  a  detailed  account  of  the  heated  war  of  words  that 
has  been  waged  between  the  Finklerites  and  those  who  support  Koch,  we 
merely  refer  to  Fig.  8  (p.  179).  Avhich  distinctly  shows  the  difference  in 
mode  of  growth,  between  the  Finkler  microbe  and  the  true  comma-bacillus, 

A  number  of  Italian  Avriters  have  also  published  adverse  criticisms  upon 
Koch  and  his  doctrine.  As  an  example  of  the  kind  of  argumentation  freely 
indulged  in,  we  may  quite  briefly  allude  to  the  polemic  of  Dr.  M.Venturoli, 
who  has  written  a  little  pamphlet,"  in  which  he  endeavors  to  show  that  the 
bacillar  theory  of  the  German  savant  is  utterly  without  foundation.  He 
says  that  the  comma-bacillus  is  not  always  present  in  the  choleraic  dis- 
charges, but  admits  that  it  is  found  in  cultures.  And  he,  therefore,  warns 
not  only  Koch,  but  more  particularly  his  own  countrymen,  that  they  ought 
to  go  very  slowly  in  describing  things  the  existence  of  which  is  as  doubt- 
ful as  that  of  the  cholera  microbe. 

Turning  for  a  moment  to  another  phase  of  the  cholera-bacillus  contro- 
versy, what  shall  be  said  of  the  foolhardy  experiment  of  Bochefontaine, 

'Archive  per  leScienze  Mediche,  vol.  viii.,  4,  1884,  p.  415. 

2  Ueber  Cholera  Asiatica.     Basel,  1885. 

3Sull  etiologia  del  Colera  Asiatico.     La  Eiforma  Medica,  36  and  37,  1885. 

^IlBacillo-vii'gula  di  Koch  e  la  Microscopia.     Bologna,  1884. 


THE  CHOLERA-BACILLUS  CONTROVERSY. 


179 


■who,  itAvill  be  remembered,  swallo^yed  pills  made  from  dejecta  of  a  woman 
who  had  died  of  cholera,  in  the  clinic  of  Dr.  A'ulpian. 

This  fluid  coutaiued  a  prodigious  number  of  vibrioiiidte  of  all  kinds  and  de- 
scriptions, among'  which,  however,  predominated  in  point  of  nmiibers  a  kind  of 
veiy  short  bacterium  which  crowded  and  whirled  about  the  field  of  the  microscope 
with  a  i-apidity  of  motion  which  made  it  difficult  for  the  eye  to  follow  them.  In 
the  midst  of  this  bacteridial  mob  one  could  easily  recognize  the  "comma"  and 
''circumflex  accent ''  bacillus.  This  fluid,  injected  under  the  skm  of  several  guinea 
pigs  in  the  laboratory,  killed  them  in  a  few  hours.  M.  Bochefontaine,  however, 
beyond  "a  little  fever,  nausea,  conA-vdsive  movement  of  the  legs,  dysuria,  loss  of 
appetite  and  constipation,"  experienced  no  bad  effect,  and  in  twenty-four  houi-s  he 
was  all  right  again. ' 

So,  too,  what  shall  be  said  of  Klein,  and  other  bacillus-eaters  ?  Merely 
that  in  their  zeal  to  disprove  Koch's  assertions,  they  have  overlooked  an 


Fig.  8.— Test-tube  cultures  of  curs-ed  bacilli,  a,  Koch's  comma-bacilli  two  days  old;  b,  the  same 
four  days  old ;  c,  the  Fiukler-Prlor  microbe  two  days  old;  rf,  the  same  four  days  old.    (Johne. ) 

essential  part  of  his  doctrine,  which  assumes  that  individual  predisposition 
to  cholera  must  exist  before  the  microbes  shall  become  potent  for  mischief, 
quite  apart  from  that  other  circumstance  of  the  destructive  action  of  nor- 
mal gastric  juice  upon  the  vitality  of  commas.  Because  ham  infected  with 
trichina?  may  occasionally  be  eaten  Avith  apparent  impunity,  Ave  do  not 
conclude  that  the  fatal  cases  of  trichinosis  are  not  invariably  due  to  the 
ingestion  of  infected  meat. 

As  a  further  illustration  of  the  kind  of  criticism  that  has  been  bestowed 
upon  Koch  and  his  doctrine,  we  may  also  instance  the  following: 

Dr.  George  "Waters,  writing  to  The  Lancet  (Januaiy  31,  1885)  from  Bombay, 
says  that  he  found  curved  bacilli,  identical  in  shape,  size,  and  appearance  with 
comma-bacilli,  in  nearly  all  microscopic  examinations  of  mucus  from  the  small 
intestines  of  persons  who  had  died  from  ordinary  affections.  He  has  also  found 
identical  organisms  in  neutral  or  slightly  alkaline  urine.  In  human  urine  he 
foimd  curved  bacilli  within  five  minutes  of  its  being-  voided  from  the  bladder. 

Nevertheless  he  regards  the  comma-bacilli  as  an  indubitable  pathological 
feature  of  cholera,  bvit  more  in  the  shape  of  a  consequence  than  a  cause  of  the 


'  Journal  de  Micographie,  quoted  in  St.  Louis  Med.  and  Surg.  Journal,  Janu- 
ary,  1885. 


130  ASIATIC  CHOLERA. 

malady.  Further  on  he  beheves  the  org^anism  in  question  should  be  regarded 
more  as  a  physiological  than  a  pathogenic  entitj'. 

He  concludes  as  follows:  "  If  I  say  tliat  a  superabundance  of  comma-shaped 
bacilli  is  found  in  the  small  intestines  of  cholera  victims,  because  it  would  appear 
that  whatever  gives  rise  to  that  ailment  brings  about  exalted  fermentation  in 
that  part  of  tlie  alimentary  canal,  I  shall,  at  least,  have  as  much  logic  in  my 
assertion  as  Koch  had  in  declaring  that  these  organisms  must  bear  a  causal  rela- 
tion to  tlie  disease." 

Now  it  is  time  that  this  kind  of  criticism  ceased  to  receive  the  dignity  of 
being  printed  in  our  leading-  medical  journals.  Waters  makes  no  cultures;  he 
merely  sees  something  that  looks  like  a  curved  bacillus,  and  immediately  pro- 
claims to  the  world  that  the  results  of  months  of  arduous  labor  and  cautious 
inquiry  go  for  naught  in  the  liglit  of  his  puerile  investigations.  As  a  matter  of 
fact,  I  have  examined  urine  both  in  health  and  disease,  Ijotli  fresh  and  stale,  and 
can  assure  you  that  I  have  discovered  no  bacteria  in  it  that  a  good  microscope 
cannot  at  once  show  to  difler  from  Koch's  commas.  And,  moreover,  as  has  been 
pointed  out  again  and  again,  even  complete  identity  of  size  and  shape  would  be 
far  from  proving  identity  in  pathological  potency  or  virulence. ' 

But  of  all  the  blows  struck  against  the  universtil  acceptance  of  Koch's 
bacillary  doctrine,  perhaps  the  most  severe  one  is  contained  in  the  paper 
read  recently  by  Klein,  before  the  Royal  Society,  and  entitled  ''  On  the 
Kelation  of  Bacteria  to  Asiatic  Cholera. ''  For  this  communication  embodied 
the  results  of  a  sjoecial  inquiry  into  the  etiology  of  the  disease,  undertaken 
at  the  instance  of  the  Government  by  Dr.  Gibbes,  Mr.  Lingard  and  the 
reader  of  the  paper. 

The  investigations  of  this  English  Cholera  Commission  have  led  to  the 
following  conclusions:'' 

1.  Koch's  statement  as  to  the  constant  occurrence  of  comma-bacilli  in  the 
rice-water  stools  of  cholera  patients  is  correct;  the  comma-bacilli  vary  greatly  in 
numbers  in  different  stools  and  in  diflerent  cases,  in  some  being  exceedingly 
scarce,  in  others  numerous.  2.  These  comma-bacilli  varj' greatly  in  length,  some 
being  twice  and  three  times  as  long  as  others,  some  well  curved,  as  much  as  to 
foi-m  half  a  circle,  others  showing  onlj^  just  a  slight  bend.  The  name  conniia- 
bacillus  is  inappropriate;  the  organism  is  more  correctly  termed  a  vibrio.  3.  Tiie 
comma-bacilli  occur  in  the  mucus-flakes  of  the  I'ice-water  stools,  as  well  as  in 
those  taken  from  the  ileum  of  a  person  dead  of  cholera.  Tlie  sooner  after  death 
the  examination  is  made,  the  fewer  conuna-bacilli  are  found  in  the  mucus-flakes; 
even  in  typical  rapidly  fatal  cases,  tlie  mucus-Hakes  taken  from  the  ileum,  and 
examined  soon  after  death  (from  between  fourteen  minutes  to  an  hour  or  an  hour 
and  a  half)  contain  the  comma-bacilli  only  very  sparingly  indeed,  and  not  to  the 
exckision  of  other  bacteria.  Our  investigations  do  not  bear  out  Koch's  statement 
as  to  the  lower  part  of  the  ileum  being,  in  acute  typical  cases  of  cholera,  almost 
"a  pure  cultivation  of  comma-bacilli.*'  In  not  one  of  the  man}' post-mortem  ex- 
aminations of  typical  acute  cases  have  we  found  such  a  state.  4.  The  mucous 
membrane  of  the  ileum,  in  typical  rapidl}^  fatal  cases,  if  examined  soon  after 
death,  does  not  contain  in  any  part  any  trace  of  a  comma-bacillus  or  any  other 
bacteria,  not  even  in  tlie  superficial  loosened  epithelium.  If  the  post-mortem  ex- 
amination be  sufficiently  delayed,  comma-bacilli  and  otlier  bacteria  may  be  found 
penetrating  into  the  spaces  of  the  mucous  membrane.  Koch's  theory  as  to  the 
comma-bacilli  present  in  the  mucous  membrane  secreting  a  chemical  poison 
inducing  the  disease  cannot,  therefore,  be  correct.  5.  Neither  the  blood  nor  any 
other  tissue  contains  comma-bacilli  or  any  other  micro-organisms  of  known  char- 
acter. 6.  The  behavior  of  the  comma-bacilli  in  artificial  media  is  not  suclr  as  to 
justify  tlieir  being  considered  as  specific.  They  grow  well  in  alkaline  and  neutral 
media,  are  not  killed  by  acids,  and  their  mode  of  growth  in  gelatine  mixtures  is 
not  more  peculiar  than  that  of  other  ]iutrefactive  bacteria;  they  show  marked 
diflerences  when  grown  in  different  media,  but  not  more  so  than  the  ordinary 
putrefactive  bacteria  when  compaied  in  their  growth  with  one  another.     The 

'  Quoted  from  a  paper  read  bv  the  editor  before  the  ]\Iedical  Society  of  the 
County  of  New  York.     The  Medical  Recoid,  February  28,  1885. 
-  British  Medical  Journal,  February  7,  1885. 


THE  CHOLERA-BACILLUS  CONTROVERSY.         Ig^ 

comma-bacillus  of  the  mouth  shows  the  same  peculiar  charactei*  of  growth  in 
g-elatine  as  Koch's  comma-bacilli.  7.  Koch  overlooked  the  fact  that  comma-bacilli 
occur  in  other  intestinal  diseases,  in  the  mouths  of  health}'  persons,  and,  as 
shown  recently,  even  in  some  common  articles  of  food.  8.  The  experiments  per- 
formed by  Koch  and  others  on  animals  do  not  in  the  least  prove  that  the  comma- 
bacilli  are  capable  of  producing  cholera  or  any  other  disease.  The  results  obtained 
by  them  ai-e  much  more  easily  explained  in  an  opposite  manner.  9.  There  is 
direct  evidence  to  show  that  water  contaminated  witli  choleraic  evacuations,  and 
containing,  of  course,  the  comma-bacilli,  when  used  for  domestic  purposes,  in- 
cluding drinking,  by  a  large  nvimber  of  persons,  did  not,  in  the  case  of  the  tanks 
near  the  Jelepara  lane,  produce  cholera.  10.  The  mucus-flakes  taken  from  the 
.small  intestine  of  a  typical  rapidly  fatal  case  of  cliolera,  contain  numerous  mucus- 
corpuscles  filled  witli  peculiar  minute  straight  bacilli;  in  this  state  they  are  found 
^vhen  the  examination  is  made  very  soon  after  death;  soon,  however,  the  mucus- 
corpuscles  swell  up  and  disintegrate,  and  then  their  bacilli  become  free.  The 
small  bacilli  are  never  mixed  in  the  mucus-Hakes.  They  are  one-third  or  one- 
fourth  the  length  of  the  comma-bacilli,  and  about  half  their  thickness.  They  are 
non-mobile;  they  grow  well  in  Agar- Agar  jelly,  but  show  in  their  modes  of  growth 
no  peculiarity  bj'  which  thej'  could  be  considered  as  specific.  When  grown  on  the 
free  surface  of  the  nourishing  material  they  form  si)ores.  11.  These  small  bacilli 
are  not  present  in  the  blood,  in  the  mucous  membrane  of  the  intestine,  or  in  any 
•other  tissue.  12.  Experiments  made  with  these  small  bacilli  on  animals  pro- 
duced no  result.  13.  Since  my  return  to  London,  I  have  ascertained  that  the 
conmia-bacilli  of  cholera  show  two  distinct  modes  of  division,  one  the  known  one 
■of  transverse  division,  and  a  second  one  of  division  in  length.  When  growing  in 
Agar- Agar  jelly  at  tlie  ordinary  temperature  of  the  room,  after  some  days  the 
bacilli  swell  up,  owing  to  the  appearance  in  their  protoplasm  of  one  or  more 
vacuoles;  as  these  vacuoles  increase,  so  tlie  comma-bacilli  become  gradually 
changed,  first  into  plano-convex,  then  into  oblong  bi-convex,  and  ultimately  into 
circular  corpuscles.  The  longer  the  original  comma-bacillus,  tlie  larger  the  final 
circle.  These  circular  organisms  are  mobile,  just  as  are  the  comma-bacilli;  and, 
by  disintegration  of  tlie  protoplasm  at  two  opposite  points,  two  perfect  more  or 
less  semicircular  comma-bacilli  are  formed.  Growing  the  comma-bacilli  in  Agar- 
Agar  jelly  kept  at  higher  temperatures  (86°-133°  F.),  the  comma-bacilli  multiply 
by  transverse  division  only;  but,  transferring-  these  to  Agar- Agar  jell}',  and  keep- 
ing- this  at  the  ordinary  temperature  of  the  room,  they  ag-ain  gradually  change  into 
circular  organisms,  which,  by  division  in  the  diameter  of  the  circle,  form  two  new 
comma-bacilli. 

From  an  examination  of  these  conclusions,  it  would  appear  that  the 
English  inquirers  boldly  take  issue  with  every  one  of  Koch's  conclusions. 
The  only  item  in  which  they  are  not  in  conflict  with  him  consists  in  their 
admission  of  the  constant  association  of  comma -bacilli  with  Asiatic  cholera. 
But  even  this  circumstance  is  not  interpreted  by  the  Englishmen  in  Koch's 
sense.  Before  passing  final  judgment  upon  the  value  of  the  British 
Commission's  opinions,  we  will  have  to  receive  the  full  account  of  their 
labors.  Their  work  seems  to  have  been  merely  negative.  New  light  is 
not  shed  upon  the  question  by  the  results  of  their  inquiries. 

So,  too,  the  recent  discussion  on  cholera,  before  the  Eoyal  Medical 
and  C'hirurgical  Society,'  while  in  many  respects  exceedingly  interesting, 
failed  to  clearly  establish  any  other  point  than  that  there  still  exists  an 
extreme  divergence  of  opinion  regarding  the  etiology  of  the  disease. 
Those  who  accepted  Klein's  statements  and  those  Avho"  sided  with  Koch 
appeared  to  be  about  equally  divided,  although  the  strongest  arguments 
were  marshaled  in  support  of  the  German  doctrine. 

From  these  mostly  adverse  criticisms  we  turn  now  to  certain  inquiries 
the  results  of  which  are  more  or  less  distinctly  confirmatory  of  Koch's 
statements.     And   it   may  be  permissible  to   remark  at  the  outset   that 

'  The  British  Medical  Journal,  31arch  28,  and  April  4,  18So. 


]^g2  ASIATIC  CHOLERA. 

lip  to  the  present,  the  supporting  observations  more  than  counterbalance 
the  negative  evidence  of  opposing  conchisions. 

The  Investigations  of  Babes. — Dr.  Victor  Babes  had  an  opportu- 
nity of  stud^-ingthe  comma-bacillus  in  Professor  CorniFs  laboratory  during 
the  cholera  epidemic  in  Paris,  in  November,  188-i. '  He  first  sought  to 
determine  whether,  as  is  maintained  by  Koch,  but  questioned  by  several 
other  observers,  the  comma-bacilli  are  always  present  in  the  intestinal  con- 
tents of  cholera  patients.  The  cases  examined  by  him  comjDosed  ten  in  the 
early  stage  of  the  disease  and  five  at  a  later  period.  In  about  one-third  of 
these  cases  the  contents  of  the  intestine  contained  scarceh'  any  other  bac- 
terial forms  than  the  comma-bacilli,  but  in  the  remainder  the  comma- 
bacilli  were  only  one  of  several  different  forms  of  micro-organisms,  and 
were  sometimes  present  in  such  small  numbers,  and  were  so  far  from  being 
characteristic  in  their  appearance,  that  it  would  have  been  hardly  safe  to 
assert  the  existence  of  cholera  from  this  examination  alone.  In  two  cases 
examhied  at  a  late  stage  of  the  disease  absolutely  nothing  was  found  that 
could  be  called  comma-bacillus.  The  author  states,  however,  that  he  has 
never  found  the  comma-bacilli  in  the  intestines  of  individuals  suffering 
from  any  other  disease  than  Asiatic  cholera.  Curved  bacilli  are  found  in 
the  buccal  secretions,  in  water,  in  decomposing  albuminous  substances 
and  in  fecal  matters,  but  they  differ  decidedly  from  Koch's  bacilli  both  in 
form  and  in  their  behavior  in  cultures.  The  results  were  very  different, 
however, when  cultures  were  made  from  portions  of  feces  or  from  the  whitish 
collections  found  lying  over  Peyer's  patches.  In  nine  out  of  ten  cases  of 
cholera  in  the  early  stages,  characteristic  cultures  were  obtained,  and  in 
the  only  negative  case  it  was  not  improbable  that  the  failure  Avas  attribu- 
table to  an  error  in  the  preparation  of  the  specimen.  Of  the  five  remain- 
ing cases  in  which  the  disease  had  existed  from  six  to  ten  days,  two  of  the 
culture  experiments  Avere  negative  in  their  results.  Koch's  method  of 
obtaining  jiure  cultures  was  followed.  It  was  often  found  preferable  not 
to  put  the  little  white  flocculus  from  the  intestinal  contents  directly  into 
the  gelatine,  but  first  to  mix  it  with  five  grammes  of  distilled  water  and 
then  to  put  one  drop  of  this  water  into  ten  grammes  of  gelatine.  In  many 
instances  these  two  methods  were  combined.  When  the  gelatine  plates 
were  exposed  to  a  temperature  of  G2^  to  68. 5°  F. ,  cultures  were  developed  at 
the  end  of  twenty  hours  in  the  form  of  small  opaque  points,  or  as  depres- 
sions the  size  of  a  millet  seed,  presenting  the  apj^earance  of  little  bubbles 
of  air.  From  the  latter,  which  were  often  present  in  very  small  number, 
were  developed  the  characteristic  cultures  differing  in  appearance  accord- 
ing to  the  degree  of  concentration  of  the  gelatine.  In  U  to  8  per  cent, 
gelatine  solutions  the  little  bubble-like  forms  were  scarcely  visible,  and 
the  culture  consisted  of  a  little  round,  somewhat  sunken  speck,  in  the 
midst  of  which  was  a  yellowish  white  point.  AVhen  the  cultures  are  not 
too  close  together — and  this  can  be  avoided  by  employing  the  above-men- 
tioned method — they  are  most  characteristic  at  the  end  of  two  days.  They 
consist  then  of  n  sharply  defined,  opaque  white  circle,  2  or  3  mm.  (a  line 
to  a  line  and  a  half)  in  diameter,  Avithin  which  is  a  second  circle  formed 
of  granules,  and  Avithin  this  the  gelatine  is  turbid  and  liquefied.  In  the 
middle  of  the  culture,  below  the  surface  of  the  gelatine,  lies  the  yellowish 
white  point  Avhicli,  Avhen  magnified,  is  seen  to  be  of  an  irregular  star  shape, 
crumbling,  and  somcAvhat  transparent.     The  thinner  the  mother  fluid  is, 

'  Prog:i'es  Meclicale,  December  6,  1884,  and  Virchow's  Arcliiv.,  vol.  S9.  part  1, 
Jiinuai-v  2.  1885. 


THE  INVESTIGATIONS  OF  BABES.  Ig3 

the  more  rapidly  is  the  culture  developed  and  the  flatter  it  is;  and  the 
harder  the  mother  substance  is  the  more  sharply  defined  is  the  depression 
corresponding  to  the  culture.  Although  many  other  bacteria  may  form, 
similar  cultures,  yet  that  of  the  comma-bacillus  in  a  10  per  cent  gela- 
tine sohition  is  perfectly  characteristic.  In  this  at  a  temperature  of  64° 
F.  after  two  days  there  is  seen  an  oblong  bubble-like  depression,  scarcely 
five  millimetres  in  diameter,  beginning  at  the  surface,  and  from  this  fol- 
lows a  white,  twisted  or  pulpy  looking  thread,  almost  one  millimetre  in 
thickness,  which  often  ends  in  a  hook-shaped  or  spherical  enlargement. 
In  agar-agar  the  bacillus  grows  almost  entirely  on  the  surface;  it  spreads 
along  in  a  thin,  rather  moist  and  pulpy,  yellowish  white,  semi-transparent 
layer  which,  at  a  temperature  of  9G°  F.  covers  the  entire  surface  within 
fourteen  hours.  The  film  of  fluid  Avhich  ordinarily  lies  over  the  firm  agar- 
agar  becomes  cloudy  and  deposits  a  white  sediment.  In  blood  serum  at 
the  temperature  of  the  body  there  is  developed  Avithin  twelve  hours,  start- 
ing from  the  point  of  insertion,  a  globular,  bladder-like,  turbid  sack,  tak- 
ing in  half  of  the  mass  of  the  serum.  Later  the  upper  portion  of  the 
serum  becomes  liquefied,  and  at  the  bottom  of  the  fluid  layer  so  formed  is  a 
light  yellowish  sediment. 

The  comma-bacilli  were  successfully  cultivated  at  a  temperature  oi 
96^  F.  in  milk,  fresh  meat,  boiled  eggs,  bouillon,  boiled  potatoes,  carrots, 
cabbage,  and  very  sparingly  in  moistened  bread  and  beans.  The  bacilli 
retained  their  life  for  forty-eight  hours,  but  formed  no  visible  cultures, 
in  fecal  matter,  cheese,  fresh  vegetables,  potatoes,  fruit-juice,  sugar- water^ 
Avater  from  the  Seine,  ciiocolate  and  coffee.  The  bacilli  died  in  distilled 
water  inside  of  twelve  hours.  A  culture  was  gradually  heated  during  four 
hours  up  to  185'^  F.  and  then  attempts  made  to  transplant  it  in  gelatine. 
Up  to  113°  F.  cultures  were  readily  developed,  but  after  a  temperature  of 
114°  to  118°  no  new  culture  Avas  formed.  At  122°  F.  transplanted  cult- 
ures Avere  developed  as  bubble-forms,  an  appearance  Avhich  undoubtedly 
indicates  a  d)nng  condition  of  almost  all  bacilli  with  A-ery  few  exceptions. 
When  rapidly  heated,  cultures  Avere  sterilized  only  at  a  temperature  of  166'^ 
to  175°  F.  Pure  cultures,  either  in  gelatine  or  agar-agar,  Avere  not  dead 
at  the  expiration  of  nearly  two  months,  but  a  culture  which  was  mixed 
for  the  same  length  of  time  Avith  filth-bacilli  contained  no  more  viable 
comma-bacilli.  When  sublimate  Avas  added  to  the  gelatine  in  the  pro- 
portion of  1  to  30,000,  traces  of  growth  of  the  comma-bacilli  were  evident 
after  several  days,  but  the  gelatine  was  not  liquefied  until  the  proportion 
Avas  reduced  to  1  to  100,000  or  1  to  150,000.  A  solution  of  the  strength  of  1 
to  15,000  was  necessary  to  arrest  the  development  with  certainty. 

The  following  disinfectants  Avere  tested  as  regards  their  action  on  the 
comma-bacilli,  the  gelatine  or  broth  being  prepared  Avith  a  definite  percent- 
age of  the  disinfectant,  and  then  sown  Avith  pure  cultures:  In  1  pint  of 
carbolic  acid  to  1,000  parts  of  gelatine,  the  comma-bacilli  were  developed, 
but  the  culture  perished  within  a  fcAV  days.  The  same  thing  occurred  in 
a  mixture  of  sulphate  of  copper  of  1:3,000-5,000;  salicylic  acid,  1:800-900: 
thymol,  1:9,000-10,000;  iodine,  1:600-800;  bromine,  1:600;  alcohol,  1:15; 
acetic  acid,  1:2,000;  sulphate  pf  quinine,  1:800  (?). 

When  a  larger  percentage  of  the  disinfectants  than  that  giA'en  in  the 
foregoing  Avas  used,  the  cultures  Avere  not  deA'eloped  at  all,  as  a  rule.  In 
Aveaker  solutions  they  Avere  developed  better,  but  still  rather  skiggishly. 
Permanganate  of  potassium  tlireAv  down  a  broAvn  sediment  in  the  gelatine, 
but  did  not  interfere  Avith  the  bacterial  groAvth. 


Ig4  ASIATIC  CHOLERA. 

Dr.  Babes  made  a  few  experiments  upon  animals  with  apparent  success. 
Two  white  mice  were  inoculated  at  the  root  of  the  tail  with  a  pure  culture 
in  gelatine,  and  both  died  after  a  few  hours.  Pure  cultures  of  the  cholera 
bacillus  were  obtained  from  the  blood  and  the  spleen,  and  in  one  of  the 
animals  that  died  twelve  hours  after  inoculation  large  numbers  of  comma- 
bacilli  were  found  in  the  whitish  fluid  contents  of  the  intestinal  canal. 
Another  mouse  was  inoculated  by  means  of  a  needle  at  the  root  of  the  tail, 
and  was  in  a  sort  of  stupor  for  several  days  after.  The  abdominal  cavity  of 
a  rabbit  Avas  opened  and  three  minims  of  a  pure  culture  were  injected  into 
the  duodenum,  but  the  animal  quickly  recovered  and  remained  well.  Two 
guinea-pigs  were  treated  in  the  same  way.  One  died  at  the  end  of  three 
days  with  diarrhoea,  and  the  intestine  presented  the  appearance  of  cholera 
with  rice-Avater  contents  and  injection  of  Fever's  patches.  The  intestinal 
matters  contained  large  quantities  of  comma-bacilli.  The  other  guinea- 
pig  recovered  completely  after  three  days.  This  experiment  Avas  repeated 
without,  however,  giving  any  positive  results.  This  writer  describes  the 
comma-bacillus  as  follows:  When  fully  developed  in  the  intestine  or  in  a 
culture  of  some  days'  growth,  it  is  seen  in  the  form  of  a  segment  of  a 
circle  and  is  of  a  pretty  constant  thickness  of  0. 4  to  0. 5  mmm. ,  and  of  a 
length  of  1  or  2  mnim.  Under  a  moderate  magnifying  power  it  seems  to 
be  homogeneous  and  of  equal  thickness  throughout  its  entire  length.  Ihit 
when  living  stained  bacilli  are  examined  under  a  high  power  {^\  Verick 
or  -^T  Hartnack  and  4  eye-piece  Avith  elongated  tube),  three  parts  are  seen : 
a  stained  integument,  colorless  contents,  and  a  strongly  stained  substance 
which  is  usually  collected  at  the  ends  of  the  roots  in  rounded,  more  or  less 
sharply  defined  masses,  betAveen  which  one  or  two  pale  spaces  are  seen, 
giving  the  appearance  of  spores.  Sometimes  bacilli  Avith  sharpened  ex- 
tremities, having  a  crescentic  appearance,  are  seen;  in  other  cases  the  ends, 
either  one  or  both,  are  thickened.  Often  tAVO  rods  are  united  in 
the  form  of  an  S,  or  several  are  joined  as  spirilla.  The  spirilla  are  thicker, 
more  homogeneous,  and  receive  a  deeper  stain  than  the  single  rods.  A 
ten-hour  culture  in  agar-agar  often  contains  very  short  bacteria  about 
0.7  mmm.  in  length,  but  they  are  nevertheless  characteristic,  one  side 
being  ahvays  concave  so  that  they  resemble  a  millet  seed  or  a  bean. 

In  their  further  dcA^elopment  the  rods  increase  in  length,  Avhile  the 
chromatic  substance  contained  Avithin  them  is  movable,  being  observed 
noAV  at  one  end,  noAV  at  the  other,  and  again  in  the  middle.  When  the 
rods  have  attained  a  certain  length  this  substance  collects  in  the  middle 
portion,  forming  sometimes  a  thickening  of  the  rod  in  this  j^art,  and  then 
through  its  center  appears  a  light  disk  at  the  point  where  the  division  is 
to  occur.  Before  the  rod  is  ready  for  division  it  is  usually  S-shaped  or 
rather  spiral.  When  division  takes  place  there  is  noticed  first  an  S  with 
an  attenuated  middle  part,  and  then  later  the  tAvo  distinct  rods  are  seen 
joined  together  by  a  fine  unstained  line  Avitli  double  contour,  Avhicli  is  long 
and  flexible,  alloAving  free  motion  to  the  separated  rods,  but  which  often 
remains  unbroken  for  a  considerable  length  of  time.  This  persists  some- 
times for  so  long  a  time  that  the  primarily  separated  rods  become  each 
again  divided  Avhilc  still  connected  by  this  intervening  substance,  so  that 
chains  of  single  rods  are  formed.  The  bacilli  often  become  elongated 
without  any  fission  taking  jilace.  In  such  cases  the  threads  thvis  formed  may 
either  sIioav  dark  points  at  the  places  Avliere  the  fission  should  occur  or 
else  may  seem  to  l)e  homogeneous  throughout.  These  spirilla  possess  a 
rapid  energetic  movement  at  first,  but  later  become  more  sluggish,  thicker. 


THE  INVESTIGATIONS   OF   BABES.  1§5 

glistening,  and  receive  a  more  intense  stain  than  do  the  rods.  The  short 
and  separate  rods  are  formed  when  the  process  of  development  of  the 
micro-organisms  is  more  rapid,  and  tlie  slower  is  the  growth  and  the 
more  nnfavorahle  for  it  is  the  mother-snbstance,  the  more  often  are  the 
longer  shapes — chains  of  bacilli  and  threads — met  with. 

About  a  year  previous  to  the  above  investigations,  which  were  made  in 
Paris,  the  author  had  examined  a  preserved  specimen  of  intestine  taken 
from  a  patient  dead  ten  years  before  of  cholera,  and  had  been  enabled  to 
demonstrate  the  presence  of  comma-bacilli.  The  specimen  was  stained  in 
an  alcoholic  solution  of  fuchsin,  then  washed  in  alcohol,  and  the  excess 
of  staining  removed  by  a  weak  sublimate  solution.  After  this  the  sections 
were  placed  in  alcohol,  then  in  oil  of  cloves,  and  finally  in  Canada  balsam. 
The  comma-bacilli  receive  a  less  clear  staining  in  sections  than  other  bac- 
teria, and  in  old  preparations  especially  they  can  be  seen  only  when  the 
sections  are  very  thin.  In  the  specimen  examined  at  that  time  the  bacilli 
were  seen  located  in  the  most  superficial  layers  of  the  mucous  membrane 
of  the  ileum.  A  peculiar  pallor  of  the  superficial  layers  of  the  mucosa,  a 
hyaline  degeneration  of  the  intestinal  glandular  epithelium,  and  a  great  in- 
crease of  granular  matters  about  the  vessels  and  at  the  borders  of  the 
changed  tissues,  were  seen.  The  same  changes  were  seen  in  the  recent 
investigations.  The  bacilli,  usually  mixed  with  fecal  bacilli,  lay  for  the 
most  part  superficially  or  else  beneath  the  swollen  hyaline  epithelium  of 
the  glands.  In  the  mucosa  the  bacilli  were  seen  lying  irregularly  in  no 
definite  order.  Later,  when  the  dysenteric-like  processes  are  added  to  the 
above-mentioned  changes,  bacilli  penetrate  into  the  deeper  tissues  where 
they  may  be  massed  together  in  considerable  numbers.  These  are  ordi- 
narily somewhat  larger  than  the  cholera-bacilli,  and  resemble  the  bacilli 
of  typhoid  fever.  In  a  few  instances  micrococci  colonies  may  be  observed 
in  the  necrosed  mucous  membrane.  Despite  careful  examination  of  the 
internal  organs,  in  which — in  the  kidneys  especially — marked  parenchy- 
matous changes  had  occurred,  no  bacteria  of  any  kind  were  found.  In 
order  to  determine  whether  there  really  are  no  comma-bacilli  in  the  blood 
and  internal  organs  in  cholera,  Dr.  Babes  made  a  number  of  culture  ex- 
periments. In  one  instance,  in  which  a  piece  taken  with  every  precaution 
from  the  kidney  was  used,  a  liquefaction  of  the  gelatine  occurred,  and  from 
this  pure  cultures  of  comma-bacilli  were  obtained.  In  no  other  case,  how- 
ever, was  this  result  obtained,  and  the  writer  is  inclined  to  attribute  his 
success  in  this  instance  to  a  possible  error  in  the  process  employed. 

In  conclusion,  the  author  states  that  his  investigations,  as  far  as  they 
go.  corroborate  Koch's  description  of  the  comma-bacillus,  and  are  in  accord 
with  those  of  Van  Ermengem,  Eietsch  and  Nicati  as  to  the  causal  relation 
between  this  bacillus  and  Asiatic  cholera.  They  showed  also  that  the 
comma-bacillus,  while  most  characteristic  when  cultivated  in  gelatine  of  a 
certain  strength  and  under  certain  conditions,  nevertheless  has  peculiarities 
of  its  own  which  render  it  distinguishable  from  other  forms  of  bacteria 
when  cultivated  in  other  media.  By  means  of  cultures  in  different 
media,  also,  the  author  was  enabled  to  throw  some  light  on  the  causes  for 
the  slight  modifications  of  form  that  have  been  described.  It  also  seemed 
desirable  to  observe  the  action  of  bacilli  in  the  various  articles  of  ordinary 
diet,  and  especially  in  Avater.  It  was  found  that  while  the  bacillus  re- 
mained viable  in  distilled  water  for  a  very  short  time  only,  in  the  ordinary 
water  supply  of  cities  and  in  river  Avater  it  lived  for  seve"n  days  and  even 
longer.     It  was  also  shown  that  the  bacilli  bore  high  temperatures  very 


18G 


ASIATIC  CHOLERA. 


ill,  and  were  killed  at  175°  F.  or,  when  the  heating  process  was  more 
gradual,  at  157.5°.  The  action  of  the  comma-bacillns  in  the  presence 
of  disinfectants  was  also  interesting,  as  it  was  shown  that  much  stronger 
solutions  Avere  necessary  to  destroy  them  than  are  needed  to  cause  the 
death  of  other  bacterial  form.  In  general  the  volatile  disinfectants  were 
found  to  be  practically  more  valuable  than  those  which  required  to  be 
brought  into  immediate  contact  with  the  bacteria. 

Doyen's  Researches. — Dr.  M.  E.  Doyen,  in  the  Gazette  des  Hopi- 
taux  December  18,  1S84,  reports  the  results  of  his  investigations  concern- 
ing cholera  during  the  recent  Parisian  outbreak.  The  Avork  was  done  in 
Prof.  Cornil's  laboratory.  The  intestinal  contents  and  viscera  of  choleraics 
were  examined  shortly  after  death.  In  every  instance  comma-bacilli  were 
found,  both  in  the  fluid  contained  in  the  bowels  and  in  the  coats  of  the 
intestine.  In  "foudroyant"  cases,  these  bacilli  were  found  as  pure  cult- 
ures inhabiting  the  duodenum  and  upper  portion  of  the  jejunum.  In 
cases  of  slow  development  the  commas  occurred  only  in  the  ileum,  and 
were  found  there  together  with  a  variety  of  other  bacteria.  Doyen  infers, 
from  this  peculiarity  a  migration  from  above  dowuAvard  of  the  comma- 
bacilli. 

In  the  liver,  kidneys  and  spleen,  especially  in  the  two  first-named 
organs,  various  bacteria  were  found,  and  raised  in  cultures.  They  included 
comma-bacilli,  diplo-cocci,  micrococci  in  chains,  and  large  rods.  Straight 
bacilli,  or  more  frequently  curved  ones,  C  and  S  shaped,  and  corkscrew-like 
organisms  were  always  encountered  in  those  viscera. 

He  attaches  great  importance  to  the  fact  that  their  presence  in  the 
interior  of  blood-vessels  was  likewise  ascertained.  The  short  interval  occur- 
ring between  death  and  the  time  of  the  examination  excludes,  according  to 
Doyen,  the  possibility  of  the  cadaveric  origin  of  his  bacteria.  He  con- 
clucles,  therefore,  that  in  cholera  a  "  complex  septicaemia"  occurs.  It  is 
of  intestinal  origin,  and  easily  explained  by  the  epithelial  desquamation. 
The  intestinal  bacteria  are  allowed  to  penetrate  into  the  walls  of  the  bowel, 
and  may  thus  enter  the  circulation.  Like  Koch  and  Nicati,  he  was  able 
to  induce  cholera  in  dogs  and  guinea-pigs. 

AVhen  Doyen  communicated  his  observations  to  the  Paris  Biological 
Society  (meeting  of  December  13th,  1884),  M.  Malassez  very  properly 
questioned  whether  the  discovery  of  cholera  bacteria  in  the  blood  could 
be  claimed  by  the  reader,  for  he  had  admitted  that  the  blood  was  exam- 
ined after  death  in  all  his  cases. 

M.  Straus  also  remarked  that  in  innumerable  specimens  of  choleraic 
livers  he  had  never  been  able  to  discover  microbes. 

The  Investigations  of  Van  Ermengem. — Dr.  Van  Ermengem  hav- 
ing made  a  series  of  investigations  touching  cholera,  communicated  to  the 
Microscopical  Society  of  Belgium,  on  October  26th,  1884,  the  following 
conclusions: 

1.  In  the  intestinal  fluids  of  patients  attacked  witli  cholera  (eight  autopsies 
and  tiiirty-four  examinations  of  stools)  tiiere  exists  an  organism  iden-Ucal  with  the 
coninia-bacillus  discovered  by  Koch. 

2.  Its  curved  shaped,  its  S-shaped  and  chain-like  groups  due  to  juxtaposition, 
and  its  occasional  formation  of  shglitly  wavy  iilaments,  give  an  assemblage  of 
niicrosco))ical  characters  whicli  render  it  easily  distinguisliable  from  pathogenic 
micro-organisms  hitherto  Ivnown. 

3.  It  Ts  more  or  less  abundant  in  the  choleraic  products  accordmg  to  the  period 
of  the  disease  and  the  time  of  examination.  In  two  rapidly  fatal  {foudroyants) 
cases  it  occurred  in  tlie  intestinal  contents  almost  in  a  pure  culture.  In  one  case 
of  siiort  duration,  where  tlie  patient  had  succumbed  with  very  marked  algid 


THE  INVESTIGATIONS  OF  VAN  ERMENGEM.  Igj 

phenomena,  there  were  very  few  comnia-hacilU  to  be  found  in  tlie  intestinal 
fluid.     Tliey  disappear  from  tlie  darker  stools  of  the  reaction  stage. 

4.  It  would  have  been  very  important  to  find  them  in  the  dejecta  of  patients 
attacked  with  so-called  premonitory  diarrhoea,  but  our  investigations  could  not 
be  brought  to  bear  on  this  point. 

5.  In  the  single  case  of  algid  cholera,  where  microscopic  examination  failed 
to  detect  numerous  comma-bacilli,  a  culture  of  a  small  quantity'  of  the  intestinal 
contents  on  soiled  linen  in  a  damp  chamber  j'ielded  an  incalculable  number  of 
charactei-istic  comma-bacilli  in  twenty- four  hours. 

6.  Microscopical  examination  of  dejecta  can  suffice  to  establish  the  diagnosis 
of  Asiatic  cholera,  when  preparations  containing  the  different  forms  of  comma- 
bacilU  in  excess  are  obtained. 

7.  Bacterioscopic  research  supplies  the  deficiencies  of  microscopical  examina- 
tion in  cases  where  the  comma-bacilli  are  scanty,  and  are  even  not  found  witli 
certainty  in  the  preparations.  The  characteristic  aspect  of  their  colonies,  studied 
under  a  low. power  (150  diam.),  renders  them  easy  of  recognition.  Tlie  practical 
value  of  tliese  culture  processes  on  the  glass  slide  in  nutrient  gelatine  (10  per  cent.) 
is  well  shown  by  our  experiments.  Mixtures  of  a  very  small  qviantity  of  the  cul- 
tivation product  with  a  considerable  amount  of  putrefied  blood,  stagnant  urine, 
fecal  matter,  hay  infusion,  etc.,  yield  preparations  wliere  the  typical  colonies  of 
comma-bacilli  have  been  detected  with  readiness  in  the  midst  of  most  varied 
vegetation. 

8.  Tlie  study  of  the  morphological  characters  of  the  comma-bacilli  at  different 
stages  of  development,  cultivated  in  various  media,  chiefly  in  chicken  broth  and 
fluid  serum,  sliows  that  they  are  nearly  related  to  true  spirilla. 

9.  The  most  varying  conditions  of  temperature  and  medium  have  not  resulted 
in  the  discovery  of  a  stage  of  spore  formation;  and  their  want  of  resistance  to 
drying  proves  that  tliey  do  not  produce  permanent  germs. 

10.  Gelatine  cultures  cease  to  be  inoculable  six  or  seven  weeks  after  having 
been  sown.  Agar-agar  cultures  still  contain  living  organisms  after  eight  to  nine 
weeks. 

11.  Tlie  temperature  most  favorable  to  their  development  seems  to  be  that  of 
from  73°  to  98.5.  °  F.  Below  61°  (between  46.5°  and  59°)  they  are  still  developed,  but 
with  difficulty. 

13.  Their  phenomena  of  grov\i;h  and  multiplication  are  extremely  active.  In 
from  two  to  three  days  they  completely  liquefy  manj^  cubic  centimetres  of  coagu- 
lated serum. 

13.  The  curved  bacilli  of  the  saliva,  discovered  by  Miller,  and  believed  by  Dr. 
Lewis  to  be  identical  with  the  choleraic  comma-bacilli,  do  not  develop  in  gelatine 
of  10  per  cent. 

14.  The  cultures  of  the  organisms,  to  which  MM.  Finlder  and  Prior  attribute 
the  production  of  cholera  nostras,  are  impure.  That  which  I  examined  contains 
two  kinds  of  bacilli.  Their  mode  of  vegetation  and  the  appearance  of  their 
colonies  in  gelatine  difter  from  those  of  the  comma-bacilli  of  Asiatic  cholera. 
One  of  them  gives  to  the  cultivating  medium  a  very  characteristic  greenish-blue 
fluorescence,  which  is  wanting  in  the  pure  cultures  of  the  comma-bacilli. 

15.  Attempts  at  inoculation  of  the  cultivation  products  have  so  far  yielded  very 
encouraging  results  in  some  species  of  animals,  such  as  dogs,  rabits  and  guinea- 
pigs.  Three  out  of  four  guinea-pigs  died  in  two  or  three  days  after  the  injection 
into  the  duodenum  of  one  drop  of  a  culture  (fourth  day)  of  the  comma-bacilli  in 
liquid  serum,  after  the  method  pursued  by  MM.  Nicati  and  Rietsch,  of  Marseilles. 
Tlie  cadaveric  appearances  were  those  of  cholera,  and  the  intestinal  fluids  con- 
tained large  numbers  of  comma-bacilli. 

16.  The  pathogenic  action  of  these  culture  products  is  probably -a  zjniiotic  one. 
The  ferment  appears  to  be  a  readily  decomposed  compound  albuminoid.  Fresh 
red  blood-corpuscles  placed  on  Ranvier's  heated  platina  stage  show  characteristic 
changes  when  brought  in  contact  with  a  drop  of  culture  serum.  These  changes 
correspond  to  those  described  by  Nicati  and  Rietsch  as  occurring  in  the  blood  of 
cholera  patients. 

17.  The  discovery  of  the  cholera-bacillus  is  of  utmost  importance  in  the  diag- 
nosis of  doubtful  choleraic  diseases  occurring  at  the  commencement  of  an  epidemic, 
and  also  for  the  establishment  of  propliylaxis;  for  an  early  diagnosis  will  enable 
us  to  institute  timely  measures  for  prevention. 

18.  The  employment  of  bacterioscopic  methods  does  not  present  great  practi- 
cal difficulties.     In  view  of  the  threatened  invasion  of  Belgium,  it  would  appear 


Igg  ASIATIC  CHOLERA. 

advisable  that  a  sufficient  nviniber  of  physicians  proceed  to  Berhn  to  acquire  the 
necessary  proficiency  in  carrying"  out  sucli  examinations. 

Still  more  recently  Van  Ermengem  presented  an  important  communi- 
cation to  the  Belgian  Academy  of  Medicine  (Bulletin  de  I'Acad.  Koyale  de 
Med.  de  Belgique,  Vol.  XVIII, ,  No.  12.,  1884),  on  the  inoculation  of 
guinea-pigs  with  the  products  of  comma-bacilli  cultures. ' 

The  avithor  begins  by  pointing"  out  that  the  transmissibility  of  cholera 
from  man  to  the  lower  animals  has  been  in  turn  affirmed  and  denied  by  manj' 
observers.  In  all  epidemics  facts  have  been  observed  which  were  thought  to 
point  conclusively  to  cliolera  infection  in  dogs,  cats,  birds,  etc. 

Reputable  authorities,  such  as  Magendie,  Meyer,  Tliiei-sch,  Cliarcelay,  Crocq, 
Legrosand  Goujon,  Leyden,  Biu-don-Sanderson,  Popotfand  others  have  conducted 
experiments  the  results  of  which  seemed  to  them  to  be  conclusive.  But  on  the 
other  hand  the  force  of  these  positive  results  has  been  weakened  by  the  negative 
conclusions  of  other  experimenters,  chief  among  wliom  are  Schmidt,  Guttmann 
and  Baginski,  Stokvis,  Snellen,  Hogyes,  Wolfi'hiigel,  and  especially  the  commis- 
sioners of  tiie  English  Sanitary  Council  in  India.  The  unfailing-  want  of  success 
in  tiie  experiments  recentl^^  vmdertaken  for  the  same  end  by  the  members  of  the 
French  and  German  missions  in  Egypt  and  Calcutta  respectively  has  tended 
still  further  to  establish  the  opinion  that  most  of  the  lower  animals  are  not  sus- 
ceptible to  the  action  of  the  cholera  poison. 

In  the  face  of  these  contradictory  facts,  it  might  be  asked  whether  the  chol- 
eraic symptoms  sometimes  observed  were  actually  those  of  cholera.  And  tliis 
doubt  is  increased  when  the  conditions  of  most  of  the  expei-iments  are  more 
closely  examined.  Not  only  were  the  symptoms  far  fi'om  being  always  charac- 
teristic, but  the  lesions  discovered  post-mortem  were  very  diverse  in  character, 
and  in  many  cases  no  autopsy  was  made  at  all.  And  besides,  many  sources  of 
error,  which  liave  since  been  found  to  exist,  were  often  not  guarded  against. 
Poisoning  by  ptomaines  miglit  explain  many  of  the  phenomena  observed;  and  the 
experiments  made  some  time  ago  by  Stich  have  shown  that  the  introduction 
into  the  circulation  of  excxementitious  products  contained  in  the  urine  or 
feces  ma^'  give  rise  to  symptoms  resembling  greatly  those  of  the  algid  stagQ  of 
cliolera.  Then  again,  it  reqvured  massive  doses  of  the  virulent  material  to  pro- 
duce tangible  results,  small  doses,  except  possibly  in  the  case  of  mice  having 
failed  to  excite  alarming  or  fatal  symptoms.  Finally,  facts  were  wanting  to  es- 
tablish the  poisonous  nature  of  the  dejections  of  the  animals  which  were  the  sub- 
jects of  experiment. 

Thus  it  may  be  said  that  the  experimental  study  of  cholera,  vmtil  very  recently 
was  just  where  that  of  tuberculosis  was  prior  to  the  memorable  investigations  of 
Villemin,  Martin  and  Koch.  Pseudo-cholera  lias  been  produced  by  matters  of 
the  most  varied  kinds,  but  proof  is  still  wanting  that  the  disease  thus  caused  is 
specific  in  its  nature  and  re-inoculable. 

Van  Ermengem  had  made  a  few  attempts  at  inoculation  in  dogs  without  very 
definite  results,  when  he  learned  of  the  experiments  upon  guinea-pigs  conducted 
b}'  Nicati  and  Rietsch.  They  seemed  to  him  important  as  indicating"  that  these 
rodents  were,  in  a  special  manner,  susceptible  to  the  action  of  the  cholera  poison, 
and  he  tlierefore  turned  his  attention  to  tliem,  using  them  in  a  series  of  searching 
and  varied  experiments. 

The  first  experiments  were  made  by  injecting  eight  to  fifteen  drops  (0.5  to  1.0 
grm.)  of  a  pure  culture  of  comma-bacilli  into  the  lUiodenum.  Every  one  of  the 
animals  died  presenting  typical  symptoms  of  malignant  cholera,  and  the  autopsA' 
revealed  lesions  whic'li  completed  the  picture  of  the  disease.  Microscopical  ex- 
amination showed  the  presence  of  comma-bacilli  in  the  contents  of  the  intestine. 

Several  guinea-pigs  were  then  submitted  to  an  injection,  in  a  similar  manner, 
of  a  fraction  of  a  drop  of  the  culture  fluid,  the  dose  varying  from  1-5  to  1-80  of  a 
drop.  Only  one  of  tiie  animals  siu'vived,  and  he  pi-esented  some  passing  algid 
sj'iiiptoms  and  liad  a  diarrlioea  for  several  days.  His  stools  contained  comma- 
bacilli  nine  days  after  the  inoculation,  which  had  been  of  about  1-50  of  a  drop 
only  of  the  culture  fluid.  All  of  the  other  animals  died  with  clioleraic  symptoms, 
difiering  but   little   in   intensity   from   those   excited   by  tlie   large  doses.     The 

1  From  an  article  by  the  editor  on  "  Recent  Researches  in  Cholera,"  published 
in  the  Medical  Record,  February  38,  1885. 


THE  INVESTIGATIONS  OF  VAN   ERMENGEM.  Jgg 

lesions  found  post-mortem  were  those  of  cholera,  and  numbers  of  comma-bacilli 
were  discovered  in  the  intestinal  contents. 

Another  series  of  experiments  was  made  to  determine  the  virulence  of  intes- 
tinal matters  taken  from  the  animals  subjected  to  the  former  inoculations.  The 
subjects  of  these  expei'iments  died  with  choleraic  symptoms,  as  did  also  other 
animals  inoculated  with  their  morbid  products,  the  latter  being,  therefore,  the 
third  in  the  series. 

Injections  were  now  made  with  the  products  of  cviltures  from  which  the  ba- 
cilli had  been  removed  by  filtration,  or  had  been  killed  by  heating-  the  culture  to 
140°  F.,  or  over,  for  half  an  liour.  In  these  experiments,  when  large  doses  wei'e 
injected,  tlie  animals  speedily  succumbed  with  algid  symptoms,  but  when  small 
quantities  were  used  no  effects  were  produced. 

To  assure  himself  against  error  the  author  also  examined  microscopically  the 
stools  and  tlie  intestinal  contents  of  healthy  guinea-pigs.  He  sometimes  found 
bacteria  of  a  curv^ed  form  and  well-developed  spirilla,  but  it  was  always  easy  to 
distinguish  these  from  Kocli's  bacilli,  for  they  were  from  two  to  four  times  larger 
than  the  latter,  and  differed  from  them  also  in  their  action  in  culture  media. 
Similar  forms  were  also  found  in  the  excrement  of  other  animals  and  in  impure 
water. 

That  the  abdominal  section  required  in  order  to  make  the  duodenal  injections 
was  not  the  cause  of  the  deatli  of  the  animals,  was  shown  by  tlie  recovery  of 
several  guinea-pigs  subjected  to  the  various  experiments,  for  in  them  the  wound 
healed  readily  witiiout  exciting-  any  untoward  complications.  Several  of  those 
animals  that  recovered  from  the  first  operation  were  used  a  second  time,  and  died 
witli  tlie  usual  choleraic  symptoms.  Tliis  would  seem  to  show  that  one  inocula- 
tion witli  the  comma-bacilli  does  not  confer  immunity. 

Duodenal  injections  wei'e  also  made  of  septic  materials  other  tlian  those  con- 
taining comma-bacilli,  and  in  most  cases  were  barren  of  result.  In  some  few 
instances  the  animals  died  with  symptoms  of  septicaemia,  but  never  with  those  of 
cholera.  * 

In  reviewing  the  results  of  his  various  experiments  the  author  maintained  that 
they  were  sufficient  to  prove  that  cultures  of  the  comma-bacilli  contain  a  very 
active  toxic  principle,  wliicli  can  only  be  the  product  of  tiie  vital  activity  of  tliis 
microbe.  This  poison  causes  morbid  plienomena  and  cadaveric  lesions,  differing 
but  little  from  those  of  Asiatic  cholera.  He  hoped  to  be  able,  with  the  assistance 
of  a  skilled  chemist,  to  isolate  this  principle,  and  to  compare  it  with  that  wliich 
Dr.  Pouchet  had  I'ecently  succeeded  in  separating  from  the  rice-water  stools.'  If 
these  attempts  were  successful  they  might  suffice  to  establish  a  very  important 
similai'ity  between  the  phenomena  observed  in  experimental  cholera  and  those 
whicli  characterize  the  disease  in  man.  In  two  autopsies  of  malignant  cholera 
matle  by  the  author,  there  was  such  an  absence  of  grave  lesions  that  it  was  diffi- 
cult to  explain  the  fatal  I'esult  by  any  chang-es  in  the  intestines  or  other  organs; 
the  blood  alone  was  profoundly  altered.  Similar  discoveries  have  i'ecently  led 
Koch,'^  Straus  and  Roux,"  and  Klebs,''  to  admit  that,  in  these  cases,  a  powerful 
poison  is  produced  in  the  intestine,  to  the  absorption  which  these  grave  constitu- 
tional symptoms  and  sj^eedy  deaths  are  to  be  attributed.  The  injection  of  filtered 
cultures.  Van  Ermengeni  stated,  has  caused  in  guinea-pigs  a  condition  presenting- 
the  strongest  resemblance  to  an  attack  of  hyper-acute  dry  cholera. 

'  Comptes  rendus  de  I'Acad.  des  Sciences  de  Paris,  No.  20,  1884. 

-  Conferenz  z.  Erorterung  der  Cholerafrage;  Deutsche  Med.Wochenschrift,  No. 
33,  1884. 

■^  Bulletin  de  I'Academie  de  Medecine  de  Paris,  August  6,  1884. 

*  De  rfitiologie  du  Cholera.  In  Ann.  de  la  Soc.  Medico-chir.  de  Litge,  No.  11. 
1884. 


190  ASIATIC  CHOLERA. 


CHAPTER    XXIV. 

THE  CHOLERA   MICROBE  OF  EMMERICH;  WITH  OTHER  OBSERVA- 
TIONS  FOR  AND  AGAINST  KOCH. 

The  Microbe  of  Emmerich. — Dr.  Eudolph  Emmerich  was  sent  by 
the  Bavarian  Government  to  Naples  for  the  purpose  of  studing  Koch's 
comma-bacihus  in  its  relations  to  Asiatic  cholera.  An  account  of  his 
observations  was  read  at  a  recent  meeting  of  the  Medical  Society  of 
Munich  (December  3,  1884).  His  material  consisted  of  ten  cases.  In 
eight  of  these  there  was  no  difficulty  in  finding  Koch's  commas.  In  the 
remaining  two  they  were  missed. 

But  in  addition  to  the  comma-bacilli,  his  glass-plate  cultures  shoAved 
colonies  of  another  variety  of  microbe.  Indeed,  the  latter  sometimes  pre- 
ponderated over  the  comma  colonies.  Believing,  however,  that  the  mere 
discovery  of  a  peculiar  organism  in  the  intestinal  contents,  and  appar- 
ently nowhere  else,  could  not  sufficiently  account  for  the  disease,  he 
decided  to  search  elsewhere  for  their  presence.  He  thought  that  the  vis- 
ceral lesions  of  cholera  might,  perhaps  (reasoning  from  analogy  with  other 
infectious  diseases),  receive  their  explanation  from  the  presence  of  cholera 
microbes  within  their  substance. 

Emmerich  examined  the  blood  and  various  organs  of  choleraic  bodies 
by  inoculating  tubes  containing  sterilized  solid  culture  media  of  various 
kinds.  These  tubes  were  then  taken  to  Munich  and  their  microbes 
studied  by  means  of  glass-plate  cultures.  In  this  way  he  discovered  a  new 
organism,  held  by  him  to  be  the  true  cholera  microbe. 

The  same  pathogenic  organism  he  succeeded  in  cultivating  from  the 
blood  of  a  young  woman  who  was  in  the  collapse  stage  of  the  disease  and 
died  six  hours  after  the  blood  was  withdrawn  from  the  median  vein.  He 
describes  his  method  of  procedure  in  the  following  manner: 

The  surface  having  been  carefully  washed  with  water,  alcohol,  and  a 
one  per  cent,  solution  of  corrosive  sublimate,  the  vein  was  punctured,  and 
the  blood,  which  was  observed  to  be  thick,  trickled  slowly  out.  The  first 
drops,  having  been  carefully  got  rid  of,  a  previously  heated  platinum  wire 
was  passed  into  the  vein,  and  on  being  withdrawn  was  then  introduced 
into  a  test-tube  containing  solidified  nutrient  gelatine,  and  the  latter  was 
pricked  in  three  places.  Ten  such  tubes  were  inoculated  in  this  manner, 
and  it  was  afterward  found  that  organisms  developed  in  three  of  them. 
The  remaining  seven  tubes  continued  to  be  sterile. 

The  organisms  thus  cultivated  were  always  of  one  kind.  They  have 
a  cylindrical  form  with  rounded  ends,  and  are  found,  either  singly  or  in 
pairs,  rarely  with  more  than  two  segments.  The  length  of  each  microbe 
is  about  one  and  a  half  times  that  of  its  width.  According  to  John's 
classification,  therefore,  they  are  bacteria,  or  better,  short  bacilli.     As  vp.- 


EMMERICH'S   CHOLERA-MICROBE.  191 

gards  shape  aud  size  the}'  resemble  those  found  in  diphtheria,,  hut  are  to 
he  distinguished  from  the  latter  hy  the  form  of  their  colonies,  when  grown 
in  gelatine  and  examined  under  a  low  power,  and  also  hy  their  action 
upon  animals.  They  grow  at  ordinary  temperatures  in  slightly  alkaline 
gelatine  as  solid  milk-glass-like  patches.  They  do  not  liquefy  the  gelatine.' 
IJnder  a  power  of  one  hundred  diameters  such  of  the  colonies  as  develop 
in  the  deeper  portions  of  the  nutrient  gelatine  on  the  glass  plate  present 
the  form  of  a  millstone,  and  those  on  the  surface  simulate  flat,  circular 
mussel-shells.  The  deeper  colonies  look  yellowish-brown  by  transmitted 
light,  Avhite  by  reflected  light,  and  have  a  finely  granular  appearance. 
The  more  superficial  colonies  are  pale  yellow  toward  the  middle,  and 
whitish  at  the  margin.  They  manifest  a  tendency  to  spread  over  the  sur- 
face as  a  thin  transparent  coating. 

In  cultures  from  the  viscera  they  were  found  to  be  most  numerous  in 
the  kidneys  and  liver,  then  in  the  lungs,  aud  least  numerous  in  the  spleen. 
Emmerich  ascertained  that  the  greater  number  of  the  gelatine  plates  which 
were  inoculated  with  the  blood  and  with  the  juices  of  the  several  organs 
in  cholera  yielded,  even  in  the  first  generation,  a  pure  culture  of  this 
bacterium.  The  microbe  has  also  been  detected  without  resorting  to  cul- 
tivation in  sections  of  the  intestine  and  of  the  kidney.  Other  organs  have 
not  as  yet  been  examined.  Great  numbers  may  be  detected  in  the  dejec- 
tions and  in  the  intestinal  contents  after  death.  They  were  found  to 
grow  in  every  gelatine-plate  cultivation  of  choleraic  alvine  material,  and 
in  some  cases  occupied  almost  the  entire  surface  of  the  plate;  whereas 
in  other  cases,  though  more  seldom,  comma-shaped  bacilli  prevailed,  but 
never  to  the  exclusion  of  the  particular  organisms  in  question. 

The  results  of  some  inoculation  experiments  made  at  the  Hygienic 
Institute  of  Munich,  in  conjunction  with  Dr.  Sehlen,  were  also  described. 
The  animals  experimented  upon  Avere  for  the  most  part  guinea-pigs,  and 
he  believed  that  lesions  had  been  induced  in  them  by  inoculation  with 
this  bacterium,  which  closely  resembled  those  observed  in  persons  who 
had  died  of  cholera,  and  especially  as  regarded  the  small  intestine.  The 
changes  had  been  noticed  to  vary  from  a  simple  desquamative  catarrh, 
with  rice-water-like  intestinal  contents,  to  hemorrhagic  exudation  and 
ulcerative  destruction  of  the  mucous  coat.  A  few  drops  of  a  solution 
prepared  by  the  addition  of  a  fragment  of  this  bacterial  cultivation  to  two 
or  three  drachms  of  distilled  water,  injected  subcutaneously  or  into  the 
lungs,  gave  rise  to  a  protracted  illness  of  from  five  to  six  days,  accom- 
panied with  deep-seated  changes  in  the  intestinal  mucous  membrane.  The 
injection  of  a  larger  fragment  of  the  cultivation,  covering  an  area  of  about 
a  quarter  of  an  inch,  suspended  in  water,  was  followed  by  death  in  from 
sixteen  to  thirty  hours,  but  with  less  marked  pathological  lesions  in  the 
intestine.  The  severity  of  the  intestinal  lesions  were  thus  the  more 
marked  the  more  protracted  the  course  of  the  disease;  and  the  larger  the 
dose  the  earlier  did  the  fatal  termination  occur. 

The  contents  of  the  colon  varied  with  the  degree  of  the  affection.  It 
was  either  a  flocculent  Avhitish  fiuid,  resembling  rice-water,  or  more  pappy, 
and  in  advanced  cases  mixed  with  blood.  The  mesenteric  glands  were 
found  enlarged,  the  peritoneum  congested,  the  ccecum  and  large  intestine 
sometimes  showed  extensive  ecehymoses.  The  spleen  ahvays  looked 
normal. 

These  assertions  of  Emmerich  were  so  direct  and  unequivocal  that 
they  created  considerable  stir  in  the  medical  world,  especially  in  German}'. 


292  ASIATIC  CHOLERA. 

llis  metliods  and  results  Avere  soon  challenged.  On  the  other  hand  he 
has  himself  quite  recently  attempted  to  substantiate  more  i'ull}^  his  claim 
to  the  discovery  of  a  new  specific  cholera  microbe.     (See  below.) 

Among  others,  Professor  Fliigge,  of  Gottingen,  the  well-known  author 
of  a  treatise  on  the  methods  of  hygienic  investigation, '  and  similar  standard 
Avorks,  has  pul)lished  a  refutation  of  Emmerich's  positive  claims.  Fliigge," 
states  that  Emmerich  failed  to  obtain  pure  cultures.  His  alleged  new 
cholera  jjacillus  is  merely  a  septic  organism.  The  results  obtained  by 
inoculating  animals  he  could  have  induced  equally  well  by  using  cadaveric 
products  from  any  body  not  too  long  dead. 

Emmerich's  method  of  obtaining  cultures  could  not  stand  the  rigid  test 
of  scientific  accuracy,  which  to-day  is  essential  for  experiments  of  this 
kind.  Apart  from  all  this,  it  was  an  error  to  assume  that  the  cholera 
microbes  must  necessarily  be  present  in  the  blood  and  viscera  in  order 
to  afford  an  adequate  explanation  of  the  symptoms  of  the  disease. 

The  profound  visceral  changes  observed  in  the  bodies  of  choleraics  be- 
longed to  protracted  cases. 

In  typical  acute  cases  rapidly  terminating  in  death,  marked  his- 
tological lesions  were  found  only  in  the  intestines.  JMoreover,  the  number 
of  cases  examined  by  Emmerich  was  so  small  as  to  make  any  attempt  at 
generalization  seem  a  priori  futile.  This  is  the  substance  of  Fliigge's 
criticism,  which  in  turn  provoked  a  rejoinder  from  another  source,, 
namely,  from  a  German  observer,  a  pupil  of  Niigeli,  Avho,  while  claiming 
familiarity  with  Koch's  methods,  disclaims  all  partiality.  This  writer.  Dr. 
Buchner,'  of  Munich,  is  inclined  to  doubt  the  etiological  importance  attrib- 
uted by  Koch  and  others  to  the  comma-bacillus.  He  questions  Avhether 
the  microbes  fulfill  the  conditions  regarded  by  Koch  himself  as  essential, 
l)efore  Ave  can  accept  them  as  the  true  cause  of  a  given  disease.  Tliese 
conditions  are  ''that  the  bacteria  can  be  iuA'ariably  detected  in  such  nu- 
merical and  local  distribution  as  to  fully  explain  the  symptoms  of  the 
disease  in  (piestion." 

Buchner  then  attempts  to  shoAV  that  the  comma-bacillus  falls  short  of 
this  desideratum.     Among  other  things  he  says:^ 

It  is  a  mistake  to  suppose  that  in  cholera  it  is  only  the  intestine  that  isafTected, 
and  that  all  the  morbid  phenomena  may  be  accounted  for  simply  by  tlie  transu- 
dation of  fluid  mto  the  intestinal  canal.  The  cases  knoAvnas  "cholera  sicca"  A'eiy 
decisively  show  that  such  is  not  the  case,  as,  indeed,  is  acknoAvledged  by  Kocli, 
Avho  assumes  that  a  poisoning  of  the  entire  system  takes  place.  This  assumption, 
Buchner  states,  appears  to  be  supported  by  the  observations  of  histologists,  which 
go  to  show  that,  eA'en  in  the  early  stages  of  the  disease,  a  finely  granular  infiltra- 
tion of  the  cells  of  most  tissues  takes  place;  consequently.  Dr.  Buchner  maintains 
the  organisms  themselves  sliould  be  distributed  in  the  tissues  generally,  whereas 
comma-bacilli  are  but  seldom  to  be  detected  in  the  intestinal  walls  even,  and  not 
at  all  in  any  of  the  internal  organs.  To  meet  the  opposition  Avhich  such  a  condi- 
tion invites,  Koch  assumes  that  the  bacilli  generate  a  poison  in  the  intestinal 
canal,  whicli  passes  into  the  circulation,  but  it  so  happens  that  the  intestinal 
mucous  membrane  is  quite  incapable  of  absorption  during  a  choleraic  attack,  even 
allowing  that  these  organisms  are  capable  of  evolving  a  virulent  poison,  which, 
howeA'er,  is  Avholly  undenionstrated. 

It  is  further  niaintained  that  no  corresponding  relation  exists  between  the 

'  Lehrbuch  der  hj'gienischen  Untersuchungsmethoden.  Von  Dr.  Med.  C. 
Fltigge.     Leipzig,  1881. 

•^  Deutsche  medicinische  Wochenschrift,  January  8,  1885. 

^  Berliner  Klinische  Wochenschrift,  February  2  and  9,  1885. 

■•  The  language  of  the  paragraph  quoted  is  borrowed  from  an  editorial  in  the 
London  Lancet  of  March  14,  1885. 


BUCHXER   ON   THE   CHOLERA-MICROBES.  193 

numbers  of  the  ha.illi  and  the  severity  of  tlie  attack,  seeing-  tliat  it  is  often  found 
that  very  severe  cases  of  cholera  have  been  observed  in  whieli  but  few  could  be 
detected,  and.  indeed,  in  which  they  seemed  to  be  absent  altogether.  Etiually  in- 
explicable on  this  theory  of  a  poison  being-  genei-ated  in  the  intestinal  canal  is  the 
extremely  rapid  reaction  whicli  is  so  frequently  observed  in  the  disease;  it  would 
be  impossible  for  the  bacilli  to  disappear  so  instantaneously  from  the  intestinal 
canal  as  to  account  for  this,  whereas  were  the  organisms  distributed  generally 
throughout  the  tissues  of  the  body,  it  might  reasonably  be  assumed  that  tliey 
could  be  rapidh-  destroyed  by  the  reaction  which  takes  place  in  the  tissue  ceils. 
Again,  the  result  of  experiments  on  animals,  hitherto  so  strongly  insisted  upon  as 
a  necessary  test  of  the  virulence  of  any  microbe,  has,  so  Buchner  claims,  in  the 
case  of  the  comma-bacillus,  been  thus  far  of  a  wholly  negative  character.'  Taking- 
all  these  facts  into  consideration,  Buchner  maintains  that  further  observations  are 
necessaiy,  and  that  such  researches  as  Emmerich's  are  not,  as  asserted  by  Fliigge, 
superfluous,  and  even  injurious,  to  the  prog-ress  of  medical  science.  It  is  advanced 
that  Fliig-ge  was  wrong  in  asserting  that  Emmerich  had  found  his  bacteria  in  only 
a  certain  proportion  of  the  choleraic  organs  examined:  he  had,  on  the  contrary, 
succeeded  in  cultivating  the  same  species  of  bacterium  from  all  the  tissues  investi- 
gated, and,  as  there  were  some  hundreds  of  gelatine  tubes  experimented  with,  any 
mere  accidental  development  of  this  organism  is  out  of  the  question.  Professor 
Fliigge  further  maintained  that  the  mortality  which  followed  the  inoculation  of 
guinea-pigs  bj'  Emmerich  was  due  to  septicjemia,  and  not  to  cholera — a  sug- 
gestion whicli  Buchner  meets  by  saying  that  whereas  in  death  as  a  result  of  sepsis 
the  spleen  is  invariably  enlarged,  this  organ  was  found  to  be  small  in  all  Em- 
merich's cases.  It  is  therefore  concluded  that  the  latter  has  succeeded  in  isolating 
an  organism  in  choleraic  tissues  which  is  capable  of  giving  rise  to  a  hitherto  un- 
observed malady  in  animals,  and  one  which  coiTesponds  in  a  marked  manner  witli 
cholera  as  observed  in  man. 

Tlie  Lancet  makes  the  following  significant  comment  concerning  the 
above : 

Without  attempting-  ourselves  to  offer  any  opinion  as  to  the  places  which  these 
two  microbes  will  occupy  in  the  future  as  i-egards  their  relation  to  the  cholera  pro- 
cess, we  think  that  sutlicient  has  been  adduced  to  show  that  when  their  respective 
claims  as  cholera-causing  agents  are  examined,  those  of  Emmerich's  bacterium 
cannot,  as  the  matter  at  present  stands,  be  set  aside,  or  simply  ignored,  in  favor 
of  the  comma-shaped  organism. 

On  the  other  hand,  as  regards  the  diagnostic  significance  of  the  comma- 
bacillus,  Buchner  asserts  that  there  can  no  longer  be  any  doubt.*  He 
alludes  to  the  fact  tliat  all  competent  observers  have  found  it.  Koch  saw 
it  in  Egypt,  India  and  France.  Kleljs  and  Ceci  found  it  in  Genoa;  Van 
Ermengem  sjiw  it;  Pfeiffer,  Babes  and  Emmerich  observed  it,  and  even 
Klein  and  Gibbes  admit  that  they  ahvays  found  it.  Every  one  of  these 
investigators  recognized  it,  according  to  Koch's  description,  not  alone 
with  the  microscope,  but  by  the  various  biological  attributes  shown  in 
artificial  cultures.  The  author  thinks  that  indisputable  credit  is  due  Koch 
for  having  discovered  by  the  aid  of  his  excellent  methods  a  parasite  pecul- 
iar to  Asiatic  cholera  that  must  necessarily  have  some  importance  in  con- 
nection Avith  the  pathology  of  the  disease. 

It  is  significant  of  the  obstinacy  Avith  which  the  cholera-bacillus  con- 
troversy is  being  carried  on  that,  as  intimated  above,  Emmerich  is  by  no 
means  disposed  to  abandon  his  claim  to  the  discovery  of  the  veritable 
cholera-microbe. 

For  at  a  recent  meeting  of  the  Munich  Medical  Society,  he  once  more 
gave  a  full  account  of  experiments,  which,  since  his  previous  publications, 

'  This  statement  by  Buchner  is  fatally  inexact,  as  appeai-s  from  the  observations 
of  Nicati  and  Rietsch,  Koch,  and  especially  those  of  Van  Ermengem. 

-  It  is  somewhat  singular  that  this  point  is  not  alluded  to  bj'  the  editorial  writer 
of  the  Lancet  referred  to  above. 
13 


194  ASIATIC  CHOLERA. 

had  been  supplemented  l)y  a  series  of  new  observations. '  He  introduced 
pure  cultures  of  his  bacillus  into  the  subcutaneous  tissue  of  many  animals, 
and  asserts  that  almost  invariably  death  occurred,  with  symptoms  closely 
resembling  those  of  human  cholera. 

Emmerich  particularly  emphasizes  the  fact  that  the  post-mortem  lesions 
were  those  of  cholera.  Moreover  he  states  that  his  so-called  ' '  Naples 
cholera-bacterium  ''  was  discovered  in  the  intestinal  contents  of  the  animals 
experimented  upon  by  sul)cutaneous  injection.  That  it  has  for  the  first 
time  been  conclusively  shown  that  micro-organisms  introduced  into  the 
blood  may  be  carried  by  that  fluid  to  the  intestines,  and  escape  into  the 
lumen  of  the  alimentary  canal. 

Emmerich  finally  claims  that  his  investigations  show  that  the  Naples 
bacterium  is  the  responsible  agent  Avhich  produces  the  lesions  of  Asiatic 
cholera,  and  he  is  convinced  that  Koch's  doctrine  is  a  theory  resting  on 
assumptions  rather  than  scientific  facts. 

As  the  matter  of  the  rival  claims  of  these  organisms  at  present  stands, 
it  is  evident  that  Koch's  doctrine  has  the  advantage  of  many  corroborative 
observations.  Nevertheless  Emmerich's  labors  will  doubtless  still  further 
stimulate  scientific  inquiry  into  the  precise  nature  of  cholera.  And  it 
would  be  a  hasty  assumption  to  suppose  that  in  the  face  of  Koch's  plausi]:)le 
doctrine,  future  research  could  teach  us  nothing  new  with  regard  to  the 
disease. 

Other  Views  and  Observations  regarding  Koch's  Doctrine. — 
Dr.  A.  Johne,^  in  a  small  volume  recently  issued,  and  again  in  an  article 
just  published  in  this  country/  asserts  that  the  comma-bacillus  is  the  specific 
microbe  of  Asiatic  cholera.  Its  discovery  in  the  dejections  of  suspected 
cases  renders  diagnosis  certain.  He  is  also  convinced  that  the  culture- 
method  of  Koch  can  readily  be  carried  out  by  the  practicing  physician. 
In  this  way  he  claims  doubtful  cases  can  be  made  certain  in  from  twenty- 
four  to  forty-eight  hours. 

Dr.  A.  PfeifTer,'*  dui-ing  the  recent  outbreak  of  cholera  in  Pavis,  had  occasion  to 
observe  twelve  well-marked  cases  of  the  disease.  The  patients  represented  differ- 
ent ages,  from  two  to  sixty-two  years,  and  both  sexes.  In  two  cases  the  attack 
terminated  fatally  within  a  few  hours.  One  case  of  "foudroyant"  cliolera  sicca 
was  also  observed.     In  six  cases  autopsies  were  performed. 

In  every  one  of  these  cases  the  comma-bacilli  were  found  either  intra- vitam  or 
post-mortem  in  the  intestines.  They  invariably  showed  a  decided  preponderance 
over  all  other  varieties  of  bacteria.  In  the  three  rapidly  fatal  cases  the  intestinal 
contents  showed  almost  nothing  beside  the  commas.  In  the  intestinal  glands  of 
liardened  specimens  the  bacilli  were  also  seen  by  Pfeiffer.  Dejections  of  patients 
afflicted  with  other  diseases  (pneumonia,  measles,  typhoid  fever,  phthisis,  )jwere 
examined,  but  no  commas  could  be  discovered. 

Pfeiffer  says  that  he  also  examined  some  swelled  mesenteric  glands  of  chol- 
eraics,  but  he  found  no  commas  in  anj'  of  them.  He  saj^s,  with  reference  to  Em- 
merich's claims,  that  he  did  not  deem  it  necessary  to  search  for  comma-bacilli  in 
the  viscera,  because  he  thinks  it  incredible  that  in  the  large  number  of  examina- 
tions made  by  Koch  that  careful  inquirer  should  have  missed  them.  The  Finkler 
bacillus  is,  he  holds,  easilj'  distinguishable  from  Koch's  comma-bacillus.  Finally, 
he  is  convinced  that  the  latter  organism  is  the  cause  of  cholera,  and  not  a  merely 
accidental  occurrence.  His  reasons  for  this  conviction  do  not  differ  from  those  of 
Koch  for  holding  a  similar  belief. 

'  Berliner  Klinische  Wochenschrift,  April  13,  1885. 

'■' Ueber  die  Koch'schen  Reincultviren  und  die  Cholera-bacillen.     Leipzig,  188."). 

^Robert  Koch,  the  conductor  of  the  German  Cholera  Commission:  His  Method 
of  Bacteria  Cultivation.  By  Professor  A.  Johne,  in  the  Journal  of  Comparative 
Medicine  and  Surgery,  April,  1885. 

■*  Ueber  die  Cholera  in  Paris.  Deutsche  Medicinisehe  Wochenschrift,  January 
8,  1885. 


DENEKFS  SPIRILLA  AND  THE  VIEWS  OF  PETRONE.         ^95 

In  the  Deutsche  Medicinische  Wochenschrift,  January  15, 1885,  Dr.  R.  Deneke, 
of  the  Gotting-en  Institute  of  H^'g-iene,  reports  the  discovery  in  stale  cheese  of  a 
species  of  curved  bacilli.  Subsequent  careful  investigations  by  approved 
methods  brought  out  the  interesting-  point  that,  morpliologically  as  well  as  biologi- 
cally, they  resembled  more  closely  the  cholera-bacilli  of  Koch  than  did  the  Finkler 
bacillus.  It  is  not  necessary  here  to  give  a  detailed  account  of  the  points  of  re- 
semblance and  difference.  The  crucial  test  was  made  by  inoculating-  guinea-pigs 
with  pure  cultures.  In  every  instance  the  fluid  to  be  tested  was  introduced 
into  the  duodenum  of  healthy  guinea-pigs  by  means  of  a  hypodermatic  syringe. 
Tlie  animal  remained  in  all  respects  well  when  the  bacilli  of  Finkler  And  the 
cheese  spirilla  were  mjected,  although  about  fifteen  minims  of  culture  fluid  was 
used.  The  same  quantity  of  liquid,  containing-,  in  one  case,  a  sing-le  drop  of 
culture  fluid  of  genuine  cholei'a,  and  in  a  second  case  onh'  half  a  drop,  was  then 
injected  in  precisely  the  same  manner  as  before.  Both  animals  promptly  died, 
and  their  intestines  contained  an  abundance  of  cholera  bacilli,  showing  that  rapid 
multiplication  had  taken  place. 

The  following  brief  summary  of  Deneke's  conclusions  may  be  read  with  in- 
terest: 

There  is  a  group  of  spirilla,  not  widely  disseminated,  in  which  the  younger  in- 
dividuals have  a  curved  shape  and  show  a  tendency  to  form  mature  spirilla  bj' 
juxtaposition.  Several  distinct  kinds  of  spirilla  belonging-  to  this  group  are  already 
known.  A  differentiation  based  merely  on  form  is  quite  difficult,  even  with  the 
aid  of  the  best  microscopes.  "With  the'  aid  of  the  culture  method,  a  differentiation 
is  much  easier.  Nutritive  gelatine  and  potato  constitute  the  best  culture  media 
for  differential  recognition. 

Solid  gelatine  is  fluidified  slowly  by  Koch's  cholera-bacilli,  much  quicker  by 
tiie  cheese  spirilla,  and  with  greatest  energy  by  the  Finkler  microbes.  As  regards 
potato,  Finkler's  microbes  grow  and  spread  readily,  and  at  comparatively  low 
temperatures,  Koch's  quite  slowly  and  only  at  higher  temperatures,  Deneke's 
cheese  spirilla  not  at  all.  In  experiments  on  animals,  the  harmlessness  of  all  but 
Koch's  comma-bacillus  has  already  been  alluded  to.  Deneke  asserts  that  Finkler's 
microbe  has  not  the  slightest  relation  to  either  simple  or  Asiatic  cholera.' 

During  the  recent  epidemic  in  Naples,  Dr.  Petrone  ^  carried  out  a  series 
of  observations,  which  are  ahnost  completely  confirmatory  of  the  statements 
of  Koch  and  his  followers.  Petrone's  method  of  staining  the  Imcteria  in 
fresh  cholera  stools  or  vomit  was  as  follows:  A  drop  of  the  liquid  to  be 
examined  was  allowed  to  fall  on  the  cover-glass,  which  was  then  heated  in 
the  flame  of  a  spirit-lamp.  It  was  then  stained  with  a  watery  one  per 
cent,  solution  of  methylene  or  aniline  blue,  containing  ten  per  cent,  of 
alcohol.  After  twelve  to  forty-eight  hours  it  was  washed  with  alcohol, 
cleared  with  oil  of  cloves,  and  mounted  in  Canada  balsam.  'With  this 
method  he  has  stained  the  characteristic  fecal  matter  and  vomit  from  one 
hundred  and  fifty  cases  of  cholera,  seventy  cases  of  cholerine,  and  fifty  of 
choleraic  diarrhoea. 

In  the  fecal  matters  from  all  the  cases  of  cholera,  and  from  the  greater 
part  of  the  cases  of  cholerine  and  choleraic  diarrhtiea,  he  found  constantly 
the  following  bacteria:  a.  comma-bacilli  of  Koch;  h.  spirals,  or  screw-like 
s])irilla;  r.  straight  and  curved  rods,  moniliform:  d.  spirilla,  S-shaped,  of 
identical  structure  Avitli  the  rods;  e.  small  round  cocci. 

He  believes  that  the  comma-bacillus  is  only  an  element  of  the  spiral  set 
free,  and  is  not,  therefore,  in  itself  a  true  bacillus.  The  spirals  are  to  be 
regarded  as  colonies  of  comma-bacilli.  Petrone's  injection  of  cholera 
matter  into  the  stomach  of  animals  gave  negative  results,  liegarding  the 
artificial  cultivation  of  the  commas  he  found  that  in  milk,  or  raw  and 
cooked  fruits,  they  flourished. 


'  From   the  editor's  previously  mentioned  article  published  in  the  Medical 
Record,  February  28,  1885. 

-  Gazzeta  Medica  Italiana  Lombardia,  November  33,  1884. 


196  ASIATIC  CHOLERA. 

On  the  leaves  of  salad,  turnip,  broccoli  and  cabbage,  they  also  grew  well. 
On  linen,  flannel  and  cotton,  the  bacteria  grew  well  if  the  cloth  was 
damp;  in  water,  also,  especially  in  marsh  waters,  since  the  nutritive  prin- 
ciples are  more  abundant.  Injections  under  the  skin  of  animals  with  the 
cultivation-liquids  gave  negative  results;  animals  fed  with  these  liquids 
had  no  symptoms  of  cholera. 

In  a  paper  read  by  Dr.  Austin  Flint,  Sr.,  before  the  New  York  County 
Medical  Association,  he  weighs  the  evidence  for  and  against  the  acceptance 
of  Koch's  doctrine.  The  result  is  that  he  announces  his  allegiance  to  the 
parasitic  view  of  the  origin  of  the  disease.     He  says: 

A  fact  which  speaks  strongly  in  support  of  the  doctrine  has  been  ah'eady 
stated — to  wit,  that,  reasoning  by  analogy,  all  infectiovis  diseases  may  be  logically 
considered  as  parasitic.  Accepting  the  trutli  of  this  statement;  the  question  is, 
whetlier  the  specific  cause  of  cholera  is  tlae  comma-bacillus,  or  some  other  micro- 
organism not  3'et  discovei'ed.  Now,  as  between  the  comma-bacillus  and  other 
intestinal  bacteria,  with  our  present  knowledge,  the  pathogenic  claims  of  tlie 
former  seem  to  be  paramount. 

Not  accepting  opposing  statements,  the  correctness  of  which  remains  to  be 
verified  or  disproved,  and  assuming  the  comma-bacillus  to  be  found  exclusively 
within  the  alimentarj^  canal,  and  onlj'  in  cases  of  cholera,  the  pathological  con- 
nection of  the  parasite  with  certain  well-marked  lesions  of  the  mucous  membrane 
of  the  small  intestine  is  to  be  considered.  These  lesions  are  either  due  to  tlie 
presence  of  the  parasite,  or  tliey  furnish  a  peculiar  soil  for  its  cultivation,  in  the 
latter  point  of  view  the  parasite  being  a  product  of  the  lesions.  Now,  epidemic 
cholera,  in  all  parts  of  the  globe  except  India,  is  an  exotic  disease  and  of  rare  oc- 
currence. In  view  of  these  facts,  is  it  not  vastly  more  improbable  that  the 
lesions  precede  the  presence  of  the  parasite  than  that  the  parasite  exists  prior  to, 
and  is  the  essential  cause  of,  the  lesions  ? ' 

In  an  article  on  the  recent  investigations  concerning  the  etiology  of 
cholera,^  Dr.  E.  H.  Fitz,  Professor  of  Pathology  in  Harvard  University, 
makes  the  unreserved  statement  that  "  the  weight  of  the  evidence  thus 
far  recorded  is  distinctly  confirmatory  of  Koch's  claim  to  the  constant 
presence  of  characteristic,  well-defined  micro-organisms  in  the  intestinal 
contents  of  cases  of  cholera,  and  nowhere  else  except  in  direct  connection 
with  the  latter."  If  the  comma-bacilli  are  specific  bacteria  found  only 
in  Asiatic  cholera,  it  follows  directly  that  they  are  to  be  regarded  as  diag- 
nostic of  Asiatic  cholera. 

From  an  analysis  of  the  recent  literature  on  cholera.  Dr.  Fitz  is  finally 
led  to  formulate  the  following  conclusions: 

1.  A  well-defined  characteristic  organism — the  comma-bacillus  of  Koch— is  to 
be  fovmd  in  all  cases  of  cholera,  especially  during  the  earlier  stages  of  the  disease. 
It  is  never  found  except  in  connection  with  cholera.  3.  It  is  present  in  such 
quantities  and  under  such  circumstances  as  to  indicate  that  it  has  an  important 
influence  in  producing  the  symptoms  and  spread  of  the  disease.  3.  When  intro- 
duced into  the  intestine  of  certain  animals  it  occasions  alterations  of  the  intestine, 
especially  of  the  small  intestine  and  its  contents,  resembling  in  appeai-ance  and 
in  composition  those  found  in  cholera.  4.  A  thorough  appreciation  of  the  proper- 
ties of  this  organism  is,  therefore,  essential  for  the  early  recognition  of  suspected 
cases  of  cholera,  and  especially  for  intelligent  attempts  at  preventing  the  origin 
and  spread  of  this  disease. 

The  following  conclusions  published  by  the  editor  in  connection  with 
a  recent  paper  on  cholera,''  seem  to  him  justifiable: 

The  detection  of  the  cholera  bacillus,  even  more  so  than  that  of  tuberculosis, 

'  The  New  York  Medical  Journal,  October  25,  1884. 

2  The  Boston  Medical  and  Sm-gical  Journal,  February  19  and  26,  1885. 

3  Medical  Record,  February  28,  1885. 


EDITOR'S   CONCLUSIONS.  I97 

is  so  entirely  dependent  upon  the  skilled  use  of  special  technical  methods,  but  re- 
cently elaborated,  that  we  should  be  surprised  that  the  discrepancies  reported  by 
different  observers  are  not  g-reater  than  is  actually  the  case.  The  concurrent  tes- 
timony of  a  large  number  of  writers  of  different  nationalities  is  now  sufficient  to 
establish  the  rule  that  particular  curved  bacilli  occur  in  Asiatic  cholera. 

Where  positive  observations  are  so  numerous  and  harmonious,  we  may  place  a 
greater  value  upon  them  than  upon  the  isolated  negative  evidences  of  a  few  experi- 
menters. As  to  the  presence,  then,  in  Asiatic  cholera  of  Koch's  comma-bacillus, 
tiiere  can  no  longer  be  any  question  of  fact.  Its  relative  preponderance  in  the  lower 
portion  of  the  ileum  is  still  somewhat  doubtful.  And  with  regard  to  the  various 
stages  of  an  attack,  and  the  differing  gravity  of  separate  cases,  some  of  those  most 
competent  to  speak  from  personal  knowledge  are  not  fully  in  accord  with  Koch, 
who  finds  the  presence  of  the  commas  related  to  them  in  such  a  way'that  severity 
indicates,  cceteris  paribus,  a  preponderance  of  bacilli,  and  vice  versa. 

Nevertheless,  by  finding  and  proving  the  identity  of  these  microbes  by  the  cult- 
ure method  of  Koch,  we  may  have  a  diagnostic  aid  that  should  not  be  ig- 
nored. It  may  not  be  often  that  such  additional  assistance  will  be  necessary, 
since  the  clinical  signs  of  typical  cholera  are  well  marked  and  well  known.  But 
it  is  notorious  that  in  the  absence  of  an  epidemic,  such  extra  aid  may  become 
absolutely  necessary  to  elucidate  a  particular  case. 

Koch's  doctrine  liarmonizes  so  well  with  the  clinical  history  of  cholera  that  it 
ought  to  be  accepted  as  the  best  theory  yet  offered  in  explanation  of  the  disease. 
But  it  sliould  be  remembered  that  a  theory  is  not  a  scientific  fact.  We  need  more 
evidence  and  renewed  experimental  observation  before  Koch's  doctrine,  in  its  en- 
tirety', can  be  made  to  permanentlj^  stand  or  hopelessly  fall.  Many  observations 
point  to  the  possibility,  mentioned  by  Koch,  of  the  comma-bacilli  producing  pto- 
maines or  similarly  virulent  products  of  vital  action  in  the  bodies  of  their  hosts. 

The  great  credit  belonging  to  Koch  consists  in  the  fact  that  he  has  pointed  out 
to  us  the  paths  along  which  future  inquiry  must  go.  We  are  to-day  able,  thanks 
to  his  excellent  technique,  to  pursue  bacteriological  researches  with  much  greater 
accuracy  and  definiteness  than  was  possible  even  a  few  years  ago.  As  with  tuber- 
culosis Koch's  discovery  of  a  distinct  organism  has  given  us  clearer  views,  so  it 
is  likely  to  be  with  cholera. 

It  is  true,  we  have  not  yet  been  able  to  ascertain  the  full  truth.  Future  \iews 
and  conceptions  concerning  the  intimate  nature  of  cholera  may  vary  as  much  as 
past  ones  have  done.  But  when  the  history  of  cholera  shail'  be  written,  fifty 
years  hence,  it  will  have  to  be  stated  that  Koch's  discovery  of  the  comma-bacillus 
constituted  a  decided  step  in  advance  ui  the  pursuit  of  scientific  truth. 


j^98  ASIATIC  CHOLERA. 


CHAPTER  XXV. 

THE  CONTAGIOUSNESS  OF  CHOLERA. 

"We  have  already  expressed  our  conviction  to  the  effect  that  cholera  is 
a  specific  infectious  disease,  and,  though  contagious,  that  it  is  not  so  in  the 
sense,  for  example,  of  the  acute  exanthemata.  That  the  peculiar  contagion 
of  cholera  resides  in  the  dejections  is  no  longer  doubtful.  That  it  is  not 
a  volatile  substance  emanating  from  the  sick  is  also  certain.  It  is  shown 
by  the  fact  that  the  immediate  attendants  upon  cholera  patients  are  less 
liable  to  contract  the  disease  than,  for  example,  the  Avasherwomen  and 
others  engaged  in  handling  the  soiled  linen,  and  than  we  should  expect 
to  observe  if  it  partook  of  the  nature  of  a  volatile  poison. 

In  the  opinion  of  the  editor,  a  practical  disregard  of  the  contagiousness 
of  cholera  (though,  as  previously  stated,  this  is  not  as  direct  as  in  the  case 
of  small-pox  and  similar  affections)  involves,  both  in  the  presence  of  an 
epidemic  and  during  the  time  of  its  expected  arrival,  graver  responsibili- 
ties than  we  have  any  right  to  assume.  Burrall '  says  truly  in  this  con- 
nection: 

The  evidence  whicJi  is  advanced  against  the  contagiousness  of  cholera  does  not 
weaken  the  accumulated  force  of  tlie  facts  in  its  favor,  some  of  which  do  not  admit 
of  a  reasonable  doubt,  but  it  only  shows  that  the  liability  to  contagion  is  dimin- 
ished, or  strengthened,  by  certain  localizing  causes. 

Preconceived  opinions,  although  honestly  taken,  have  been  in  many  instances 
an  obstacle  to  the  belief  in  the  communicability  of  cholera  from  individual  to  in- 
dividual, and  the  same  result  has  been  produced  in  others  from  a  failure  to  apjM-e- 
ciate  tlie  indirect  manner  in  which  the  disease  is  believed,  on  good  evidence,  to  be 
communicated. 

It  is  proper  to  state,  hoAvever,  that  even  at  the  present  day  many  phy- 
sicians in  India,  long  familiar  with  cholera,  still  doubt  its  specific  conta- 
giousness. Thus  Dr.  Morehead's  observations  apparently  support  the  vicAV 
of  the  non-spreading  of  cholera  in  hospitals  through  contagion.  They 
were  conducted  Avith  care  through  three  epidemics  in  Bombay,  and  though 
lie  refrains  from  drawing  positive  conclusions,  his  experience  is  not  in 
favor  of  contagion.  Sir  .Joseph  Fayrer  states  that  he  has  seen  hundreds 
of  cases  of  sporadic  and  epidemic  cholera,  but  has  seen  nothing  to  make 
him  believe  there  is  auA'thing  of  contagion  in  connection  Avith  the  disease. 
Dr.  J.  R.  LcAvis  Avrites  that  for  fourteen  years  he  has  studied  cholera, 
and  has  never  seen  anything  to  lead  him  to  think  it  contagious.  It  Avas 
the  custom  in  India  to  treat  cholera  in  the  same  wards  as  other  diseases, 
and  no  evil  resulted. 


1  Asiatic  Cholera.     Bv  F.  A.  Burrall,  M.  D.     New  York:  W.  Yv'ood  &  Co.,  1866. 


THE  CONTAGIOUSNESS   OF   CHOLERA.  199 

Among  those  who  maintain  that  cholera  is  a  non-contagious  disease. 
Dr.  J.  M.  Cunningham,  the  surgeon-general  and  sanitary  commissioner 
to  the  government  of  India,  occupies  a  prominent  place.  His  opinions,  as 
laid  down  in  a  work  that  has  just  ai:)peared,'  are  diametrically  opposed 
to  those  of  the  contagionists,  and  especially  the  positive  assertions  of  Koch 
and  his  followers  as  regards  the  etiology  of  this  disease. 

He  makes  this  sweeping  assertion  concerning  the  doctrine  of  Koch: 
"  The  whole  superstructure  which  the  German  Cholera  Commission  raised 
on  the  supposition  that  the  comma-bacillus  is  an  organism  peculiar  to 
cholera,  and  which  was  viewed  with  such  ready  approval  both  by  the  public 
and  a  great  part  of  the  medical  profession,  has  in  fact  tumbled  to  the 
ground.^'  Elsewhere  he  declares  that  "  from  the  record  of  about  8,000 
attendants  on  cases  of  cholera  in  India  it  is  proved  that  they  suffer  no 
more  than  other  people  living  in  the  same  place.  There  is  no  danger  in 
attendance  on  cholera  cases."  Surgeon-General  Hunter,  in  his  report  on 
the  recent  cholera  epidemic  in  Egypt,  after  quoting  the  above,  adds: 

My  personal  experience  of  cholera  in  India  is  in  accordance  with  the  opinions 
above  expressed.  Tlie  professional  staff,  a  large  body  of  students  and  attendants 
of  the  Medical  College  and  Hospital,  Bombay,  who  were  more  or  less  in  frequent 
communication  with  cases  of  cholera,  and  many  of  whom  were  also  engaged  from 
time  to  time  in  performing^  post-mortem  examinations,  appeared  to  enjoy  com- 
parative immunity  from  the  disease  without  any  special  precautions  being  taken. 
Experience  gained  during  the  recent  epidemic  in  Egypt  confirms  still  further  these 
facts.  It  was  no  uncommon  thing-  to  hear  from  medical  officers  and  otliers  that 
their  clothing  and  persons  had  been  covered  with  the  discharges  from  cholera, 
patients,  which  had  been  allowed  to  become  dry,  yet  no  evil  results  followed. 
Circumstances  rendered  it  necessary  that  the  British  officers  serving  with  the 
Egyptian  army  should  attend  on  the  cholera  sick,  wash  the  bodies  after  death, 
according  to  Moslem  visage,  and  afterward  bviry  them,  and  yet  in  no  single  in- 
stance, if  I  am  correctly  informed,  did  tliey  contract  the  disease. 

The  Recent  Discussions  on  Cholera  before  the  Paris  Acad- 
emy of  Medicine. — Allusion  must  here  be  made  to  the  j^rolonged  discus- 
sions which  took  place  at  many  successive  meetings  of  the  Paris  Academy 
of  Medicine  during  the  summer  and  fall  of  1884.  Two  principal  theories 
were  enunciated  as  to  the  nature  of  cholera.  M.  Jules  Kochard,  and  a 
majority  of  the  members  of  the  Academy,  held  to  the  theory  of  personal 
contagion  and  the  importation  of  the  disease  through  human  intercourse 
and  the  medium  of  fomites.  M.  Jules  Guerin,  on  the  other  hand,  cham- 
pioned the  cause  of  the  believers  in  the  spontaneous  origin  of  cholera.  Al- 
though an  able  orator,  a  learned  physician,  and  a  gentleman  of  unquestion- 
able sincerity,  he  received  but  slight  support  from  his  fellow  members.  On 
the  other  hand  his  views  were  shared  by  many  of  those  who  had  recently 
been  brought  into  personal  contact  with  the  disease  in  the  south  of 
France. 

In  reviewing  the  Academy  discussions.  Dr.  J.  P.  Bonnafont  ^  recalls  the 
oscillations  regarding  the  doctrine  of  contagion,  in  the  last  half  century. 

From  1830  to  1849  nineteen-twentieths  of  the  physicians  in  France  were  non- 
contagionists.  From  1850  to  1880  almost  the  exact  opposite  prevailed.  And  in 
1884  he  states  that  there  were  as  many  or  more  non-contagionists  as  believers  in 
contagion,  and  the  indications  were  that  the  pendulum  would  soon  swing  well 

'  Cholera:  What  can  the  State  do  to  Prevent  it?  By  J.  M.  Cunningham,  M.D., 
Surgeon-General  Indian  Medical  Department,  and  Sanitaiy  Commissioner  with 
the  Government  of  India.     Calcutta,  1884. 

^  Le  Cholera  devant  I'Academie  de  Medecine.  La  Contagiosite  et  les  Quaran- 
tames.     Paris:  J.  B.  Bailliere  et  Fils.     1885. 


200 


ASIATIC  CHOLERA. 


over  to  the  negative  side.  The  contagionists  of  late  years  have  attempted  to 
effect  a  sort  of  compromise  with  their  opponents  by  maintaining  that  tliere  are 
two  kinds  of  cholera — one  contagious,  the  imported  or  Asiatic  cholera;  the  other 
non-contagious,  sporadic  cholera,  or  as  Favivel  called  it,  cholera  nostras.  This  new 
doctrine  is  the  one  which  seemed  to  be  most  in  favor  among  the  members  of  the 
Academy  of  Medicine.  At  the  beginning  of  the  epidemic  M.  Fauvel,  in  an  endeavor 
to  calm  the  excited  fears  of  the  public,  declared  before  the  Academy  that  the  disease 
was  of  tlie  sporadic  variety , and  was  consequently  not  contagious,  and  would  remain 
limited  to  tiie  two  cities  in  which  it  then  was.  But  when  the  disease  passed  the 
bounds  set  for  it  by  M.  Fauvel,  MM.  Brouardel  and  Proust  were  dispatched  by  tlie 
Minister  of  Commerce,  and  M.  Rochard  by  the  Minister  of  Marine,  to  study  the 
progress  and  the  character  of  the  disease.  These  three  i-eported,  contrary  to  the 
opinion  put  forth  by  M.  Fauvel,  that  the  epidemic  was  one  presenting  all  the 
characteristics  of  Asiatic  cholera,  and  that  the  disease  was  therefore  highly 
contagious.  The  first,  while  avowing  that  quarantine  alone  could  hinder  the 
spread  of  the  disease,  stated  squarely  that  it  was  impossible  to  maintain  a  quaran- 
tine by  land.  There  were  then  two  opposite  systems  in  force — one  on  the  side  of 
the  sea  condemning  the  unfortunate  travelers  to  a  long  period  of  detention;  the 
other  on  land  allowing  the  inhabitants  of  the  infected  districts  to  go  forth 
freely,  sowing  the  epidemic  along  their  route,  without  fear  of  the  bullets  of  the 
sanitary  guards. 

The  advocates  of  the  spontaneous  theory,  who  believe  that  cholera  may  arise 
and  be  propagated  in  any  locality  without  being  contagious,  assert  also  that  the 
atmosphei-e  may  undergo  changes  rendering  it  capable  of  producing  the  disease. 
But  tliey  believe  tlaat  the  air  is  always  tlie  medium  of  transmission,  and  on  tliis 
point  they  are  in  accord  with  some  partisans  of  the  importation  theory.  It  is  very 
evident,  5l.  Bonnafont  asserts,  that  the  air  is  the  only  vehicle  which  can  transport 
to  great  distances  from  its  point  of  origin  any  infectious  ]n-inciple  whatever;  but 
it  could  never  be  the  generator  of  this  princii)le.  In  support  of  this  assertion  that 
it  is  possible  for  the  contagion  to  be  transported  through  great  distances  by  tiie 
air,  he  mentions  the  carrying  of  the  ashes  thrown  out  by  the  recent  volcanic 
eruption  in  Java. 

M.  Jules  Guerin  supported  the  doctrine  of  the  spontaneous  origin  of  cholera, 
maintaining  that  it  can  originate  and  be  reproduced  in  any  country  whatevei'. 
And  M.  Bonnafont  agrees  with  him  in  so  far  as  he  denies  the  contagiousness  of 
the  disease,  citing  numerous  facts  and  authorities  in  his  support.  He  asserts  that 
■"the  transmission  of  cholera  from  one  individual  to  another  is  scientifically  im- 
possible." And  he  asks  liow  it  is  possible  to  believe  that  one  pei-son  can  introduce 
the  disease  into  a  previously  healthy  district,  when,  as  in  the  liospital  of  the  mili- 
tarj^  school  at  Constantinople,  in  1855,  nearly  1,500  cholera  patients  were  treated 
during  the  coui-se  of  a  year,  and  not  one  of  the  attendants  suffered  from  the  tii-st 
symptom  of  the  disease.  He  quotes  M.  Cazalas  as  asserting  most  emphati- 
cally tiiat  cholera,  which  is  contracted  by  infection  in  a  cholera  district  just  as 
intermittent  fever  is  contracted  bj^  infection  in  a  malarious  region,  is  neither 
directly  nor  indirectly  contagious.  M.  Bonnafont  coiicludes  his  monograph  bj' 
the  statement  that  "he  opposes  most  strenuously  every  form  of  quarantine  as 
useless,  since,  as  he  believes,  the  atmosphere  is  the  sole  vehicle  for  the  transmis- 
sion of  the  cholera  poison,  and  the  air  cannot  be  made  subject  to  quarantine 
regulations. 

Gocdeve's  Opinion. — Goodeve,,  an  English  writer  of  large  experience 
in  India,  says: 

A  volatile  poison,  at  all  strong  in  its  action,  would  be  most  dangerous  to  all 
about  the  sick,  and  yet  in  India  the  medical  men,  nurses,  hospital  coolies, 
sweepei-s,  and  others  who  are  constantly  engaged  about  the  sick  do  not  appear  to 
be  more  liable  than  the  rest  of  the  population.  The  disease  seldom  spreads  from 
bed  to  bed  in  a  ward;  on  the  contrary,  when  people  are  attacked  in  hospital  tliey 
lie  generally  in  a  distant  corner,  or  "^iu  another  ward.  I  have  noticed  this  over 
and  over  again,  and  though  I  liave  been  connected  with  the  larger  hospital  of  the 
medical  college  at  Calcutta  for  many  years,  I  do  not  recollect  any  spreading 
to  the  nearest  or  neighboring  patients.  I  should,  as  far  as  my  own  experience 
goes,  say  tliat  cholera  does  not  spread  from  the  sick  to  the  whole  by  any  rapidly 
acting  emanation. 

Other  Views. — Against  the  foregoing  and  many  similar  statements 


THE  CONTAGIOUSNESS  OF   CHOLERA.  201 

from  far  less  competent  writers,  we  liave  the  2)ositive  evidence  of  a  large 
number  of  accurate  observers.  Only  a  few  illustrations  in  point  are  here 
introduced. 

From  the  epidemic  of  18G1  the  India  commission  found  that  for  the 
whole  of  the  troops  attacked  in  thirteen  stations,  the  "  virulence  of  the 
disease  among  hospital  patients  Avas  clearly  more  than  twice  as  great  as 
it  was  among  the  healthy  strength  of  the  regiments." 

Writing  in  18GG,  Burrall  states  that 

The  opinion  of  physicians  in  Europe  has  been  tending  toward  a  belief  in  the 
contagious  natvue  of  cliolera.  During  the  last  epidemic  in  Paris,  the  cholera 
patients  were  treated  in  sepai-ate  wards,  and  tlie  administration  ordered  the  imme- 
diate removal,  cleansing  and  disinfection  of  the  bedding  used  by  cholera  patients, 
as  well  as  the  washing  and  fumigation  of  the  personal  clotliing. 

M.  Velpeau  considers  the  contagious  character  of  the  disease  proved  to  a  cer- 
tainty, and  the  same  is  true  of  other  prominent  European  2:)hysicians. 

The  views  of  M.  Jules  Worms,'  who  has  had  a  very  large  personal  ex- 
perience with  cholera,  may  also  be  cited  in  this  connection.  He  stated 
at  a  meeting  of  the  Paris  Academy  of  Medicine  that 

On  the  banks  of  the  Ganges,  and  under  conditions  which  are  not  well  under- 
stood, a  special  agent,  poisonous  to  a  large  number  of  individuals,  is  produced. 
Tliis  agent  shows  itself  among  individuals  who  are  collected  together  in  rest  or 
motion,  but  always  presents  an  uninterrupted  connection.  The  cholera  is  a  malady 
transmissible  by  man.  This  agent  manifests  its  influence  on  certain  human  being's 
(jirobably  also  on  certain  animals)  by  mild  or  severe  effects.  The  proportion  of 
inihviduals  liable  to  the  poison  can  onh*  be  approximately  estimated,  and  is  under 
all  circumstances  very  small.  The  human  system  may  become  a  fruitful  field  for 
the  multiplication  of  this  agent  as  soon  as  its  poisonous  effects  are  manifested. 
The  multiplication  of  this  poisonous  ag-ent  takes  place  chiefly  in  the  alimentary 
canal.  The  vomitings  and  dejections  of  cholera  patients  contain  the  active  agent 
of  the  transmission  of  the  disease.  This  communicability  does  not  correspond  to 
the  time  when  the  dejections  are  voided,  but  is  developed  a  few  days  subsequently, 
and  seems  to  be  exhausted  at  the  end  of  from  fifteen  days  to  three  weeks.  The 
corpses  of  cholera  patients  emit  the  toxic  agent  in  a  greater  deg-ree  than  the  bodies 
of  the  sick.  Persons  attacked  mei-ely  with  choleraic  diarrhoea  (cholerine)  void 
with  their  dejections  tlie  agent  which  is  capable  of  producing  confirmed  cholera 
in  their  vicinity.  The  greater  or  less  density  of  the  soil  on  which  the  dejections 
are  cast  diminishes  or  favors  the  propagation  of  the  disease. 

The  late  lamented  Dr.  Elisha  Harris,"  in  1865  made  the  following  state- 
ments embodying  his  experience  at  the  Staten  Island  quarantine,  with 
regard  to  the  contagiousness  of  choleraic  dejections: 

In  studying  the  histovy  of  fourteen  epidemics  of  cholera  that  have  occuiTed 
within  the  walls  of  our  New  York  quarantine  establishment,  the  writer  has  seen 
abundant  evidence  of  the  infectious  agency  of  the  sick  and  their  ''■rice-water" 
evacuations.  Ten  of  these  epidemics  at  Quarantine  unquestionably  depended 
upon  cholera  patients  from  sliips,  and  in  six  instances,  at  a  time  when  there  was 
no  cholera  upon  our  Atlantic  coast.  These  sucklen  outbursts  of  cholera,  as  a  gen- 
eral rule,  occurred  within  a  period  of  four  days  from  the  disembarkation  of  the 
sick;  and  whenever  cholera  was  not  generally  epidemic  in  this  country,  these  epi- 
ilemics  at  Quarantine  ceased  as  suddenly  as  they  came,  after  sweeping  off  a  por- 
tion of  the  convalescents  and  patients  that  were  in  other  hospital  buildings,  hav- 
i  ng  other  diseases.  The  cholera  patients  wei-e  kept  as  remote  from  other  patients 
us  possible. 

Concerning  these  repeated  outbreaks  of  cholera  at  Quarantine,  it  should  be 
stated,  that  while  tliey  prove  how  fatally  infectious  the  cholera  poison  may  be- 
come in  the  midst  of  crowded  hospitals  and  public  institutions,  they  utterly  failed 

'  Archives  generales  de  Medecine,  Nov.,  1865,  p.  623. 

-  Report  on  Epidemic  Cholera  by  the  Council  of  Hygiene  and  Public  Health  of 
tlie  Citizens'  Association  of  New  York.     New  York,  November,  1865. 


202  ASIATIC  CHOLERA. 

to  prove  that  from  the  same  exclusive  cause — viz.,  the  contagion  of  the  cholera 
evacuations — a  world-wide  epidemic  could  be  caused.  These  outbreaks  did  prove, 
however,  tliat  the  stools  and  besmeared  clothing-  of  the  sick  with  cholera  can, 
under  cei'tain  circumstances,  propagate  the  disease;  while,  on  the  other  hand,  a 
series  of  events  at  Quarantine  and  in  the  city  demonstrated  that,  for  the  produc- 
tion of  a  wide-spread  epidemic,  other  important  causes  tlian  the  presence  of  the 
"  rice-water"'  stools  and  vomitings  must  be  present. 

Dr.  Biidcr  lias  also  collected  a  number  of  instances  in  which  the  spread 
of  cholera  was  apparently  prevented  by  an  immediate  disinfection  of  the 
discharges.     Some  of  these  instances  are  here  reproduced: 

Immediate  disinfection  was  tried,  at  his  suggestion,  in  the  year  1854,  at  Fish- 
ponds, in  the  workhouse  situated  there  for  the  reception  of  tlie  Bristol  poor.  In  1849, 
cholei-a,  brought  in  by  a  woman  coming  from  an  infected  quarter  in  Bristol,  killed, 
in  this  same  workhouse,  more  than  130  out  of  less  than  600  inmates. 

In  1854,  although  the  pest  was  introduced  into  the  workhouse  three  sepai*ate 
times,  only  eight  died  of  it,  and  the  total  number  of  attacks  was  under  thirty. 

In  the  prison  of  Kaisheim  cholera  was  introduced  by  a  prisoner  who  died  there. 
The  sanitary  conditions  of  the  prison  were  as  bad  as  possible,  but  the  choleraic 
dischai'ges  were  disinfected,  and  the  result  was,  that  only  one  of  the  500  other 
prisoners  took  tiie  disease.  In  the  prison  of  Elrach,  on  the  contrary,  where  no 
measures  of  this  kintl  wei'e  taken,  of  350  prisoners,  tifteen  per  cent,  perished. 

At  Traunstein,  in  Bavaria,  in  every  case  in  which  tlie  I'ice-water  discharges 
were  disinfected  the  disease  ceased  with  the  person  first  seized. 

In  conclusion,  lie  mentions  the  case  of  a  planter  in  the  Island  of  St.  Vincent, 
who  ascribes  tlie  almost  entire  escape  of  his  laborers  from  cholera  in  the  great 
epidemic  of  1853  to  similar  measures.  When  cholera  broke  out  on  his  estate,  he 
encamped  all  his  negroes  on  open  ground,  and  by  the  advice  of  one  of  his  friends, 
had  a  pit  dug  in  the  earth  and  deeply  charged  with  chloride  of  lime,  to  serve  as  a 
receptacle  for  all  discharges  from  the  sick.  The  result  was,  that  while  the  neigh- 
boring estates  were  all  ilecimated  by  cholera,  and  some  almost  depopulated  by  it, 
this  gentleman's  estate  escaped  with  only  a  slight  outbreak. 

Lebert's  views  are  very  much  in  accordance  with  our  own  conceptions 
concerning  the  point  under  consideration.  He  has  found  many  examples 
showing  rapid  contagion  by  means  of  fresh  excretions.  The  manner  in 
which  cholera  attacks  those  who  come  in  contact  with  patients,  their  dis- 
charges, linen,  or  dead  bodies  is,  he  explains,  quite  in  harmony  with  the 
l^arasitic  doctrine.     He  says: 

I  have  noticed  in  all  epidemics,  and  have  seen  it  mentioned  in  the  wTitings  of 
many  authors,  that  practicing  physicians,  even  liospital  physicians,  are  seldom 
attacked  with  cholera,  because,  although  they  come  in  contact  with  many 
patients,  their  stay  with  each  is  short,  and  because,  when  themselves  attacked, 
they  immediately  treat  the  prodromic  diarrhoea.  But  the  resident  physicians, 
and  more  especially  the  assistants  and  nurses,  are  much  more  frecjuentl}'^  at- 
tacked. Their  contact  with  the  sick  is  much  more  protracted,  and  not  unfre- 
quently  local  epidemics  are  developed  in  hospitals  which  ett'ect  transient  visitors 
rarely  or  but  slightly,  wliile  residents,  or  those  whose  stay  is  longer,  are  attacked 
much  more  frequently  and  intensely. 

Finally  he  gives  the  following  unequivocal  expression  to  his  convictions: 

The  much-agitated  question  concerning  the  contagion  of  cholera,  whether,  if 
it  be  considered  contagious,  it  is  spread  by  a  miasma  or  contagium,  must  be  con- 
sidered, under  the  light  we  now  possess,  as  follows:  That  cholera  can  be  spread 
only  by  contagion,  i.e.,  by  germs  which  are  carried  from  a  diseased  to  a  healthy 
person;  but  that  tliese  disease  germs  infect  only  comparatively  rarely  by  inter- 
course or  contact  with  cholera  patients,  since  they  possess  relatively  but  little 
vitiility  in  the  air  of  the  sick  room,  and  are  present  mostly  in  inconsiderable 
quantity.     On  the  other  hand,  a  certain  nimiber  of  the  germs  and  a  giv^en  vitality 

'  Memoranda  on  Asiatic  Cholera;  its  Mode  of  Spreading  and  its  Prevention.  Bv 
William  Budd,  M.D.,  etc.     Bristol,  1865. 


THE  CONTAGIOUSNESS  OF  CHOLERA.  203 

are  necessary  for  the  propagation  of  tlie  disease,  and  tliese  conditions  are  better 
met  in  fluids  than  in  tiie  air;  lience  contagion  is  more  frequent  when  the  germs 
are  conmiunicated  through  a  fluid  than  when  transmitted  through  the  air. 
Should  the  germs  of  cholera  excretions  fall  into  a  privy,  for  instance,  and  from 
here  find  their  way  by  filtration  into  drinking-water  or  subterraneous  habitations, 
the  individuals  who  had  appropriated  the  most  germs  would  suffer  most  severely. 
The  danger  of  contagion  in  cholera,  tlierefore,  is  relatively  less  from  direct  con- 
tact with  cholera  patients  than  from  frequent  contact  with  tiie  insidious  and 
latent  germs  proliferated  from  these  patients.  As  these  germs  are  more  or  less 
confined  to  their  locahties  of  origin,  and  as  they  develop  moi-e  especially  in  fluids, 
the  water  of  the  soil  and  drinking-water  must  play  an  important,  although  not 
an  exclusive,  role  as  vehicles;  cholera  excretions,  too,  are  the  frequent  though 
by  no  means  the  sole  carriers  of  the  germs;  indeed  they  may  even  lack  eveiy 
element  of  contagion.  We  are  justified  at  the  present  day  in  attaching-  but  little 
etiological  value  to  tlie  idea  tiiat  cholera  may  spread  its  contag-ion  to  great  dis- 
tances under  certain  conditions  of  the  atmosphere  and  with  certain  winds. 

In  his  recent  article  on  cholera^  Stille  is  even  more  emphatic.     He  says: 

It  is  sometimes  said,  and  oftentimes  repeated,  that  cholera  is  not  directly  con- 
iagious — is  not  communicated  by  the  sick  to  the  well.  No  statement  could  be 
more  unfounded.  Tlie  whole  history  of  cholera  proves  that  tlie  physicians  and 
nurses  of  cholera  patients  are  often  affected  by  the  disease. 

Griesinger,  in  his  excellent  treatise  on  the  infectious  diseases/  has 
also  collected  some  striking  evidence  touching  the  communicability  of 
cholera,  of  which  the  following  is  a  summary. 

The  spread  of  cholera  through  the  agency  of  patients  suffering  from 
the  disease  seems  in  many  cases  very  evident.  A  little  community  of  in- 
dividuals, as  a  household,  or  the  inmates  of  a  public  institution,  of  a 
hospital  or  of  a  single  ward  of  a  hospital,  may  have  been  free  from  an  in- 
A^asion  of  the  disease  during  the  prevalence  of  an  epidemic.  Now  one  or 
more  cholera  patients  are  introduced,  whereupon  suddenly  several  of  the 
community  will  be  seized  with  the  fatal  malady.  Amon^  the  most  strik- 
ing instances  of  this  sort  are  those  related  by  Magoun  as  occurring  in  the 
hospital  at  Kieff,  by  Ebers  in  Breslau,  by  Briquet  in  Paris,  by  Haller 
and  Dittel  at  Vienna.  Gietl  states  that  of  the  326  cases  of  cholera  treated 
in  the  city  hospital  at  Munich  in  1836-7,  106,  or  32  per  cent.,  acquired 
the  disease  in  the  institution.  In  the  epidemic  at  Paris  in  1853-4,  one- 
third  of  the  cases  treated  in  the  hospitals  Avere  attacked  there  (Gazette 
Ilebdomadaire,  185-4,  p.  410).  And  indeed  in  the  first  half  of  March,  1854, 
of  the  55  cases  treated  at  the  Charite,  48  began  in  the  hospital.  J. 
Keuss  states  that  in  Strasbourg  in  1849,  7  per  cent,  of  the  hospital  popu-. 
lation  were  attacked  with  cholera,  while  the  rate  in  the  city  was  only  a 
little  over  j^  per  cent;  and  in  1854  there  was  again  a  rate  of  7  per  cent, 
attacked  in  the  hospital  and  only  |  per  cent,  in  the  city  outside.  Con- 
cerning the  Vienna  hospital  in  1854,  C.  Haller  says:  "  As  a  rule  one  case 
of  the  disease  was  always  followed  by  several,  and  sometimes  by  very  many, 
in  the  same  ward." 

It  might  seem  that  these  instances  proved  little  in  regard  to  personal 
contagion,  since  they  occurred  during  the  prevalence  of  an  epidemic,  and 
among  individuals  exposed  to  unfavorable  influences  from  hospital  air  and 
overcrowding.  But  on  the  one  hand  the  general  population  lived  under 
much  more  unfavorable  conditions;  and  on  the  other  the  new  cases  often 
broke  out,  not  in  the  most  crowded  and  unhealthy,  but  in  the  best  venti- 
lated wards.     The  disease  broke  out  only  after  cholera  patients  had  been 

'  Infections-Krankheiten  von  Professor  Griesinger.  in  Virchow's  Handbuch  der 
k:>"*ec.  Pathologie  und  Therapie.     Erlangen,  1864. 


204  ASIATIC  CHOLERA. 

received,  and  then  spread  step  by  step  from  the  beds  and  wards  where 
they  were,  stopped  when  no  more  patients  were  received,  and  began 
again  upon  the  advent  of  neAV  cases  from  witliout.  On  the  other  liand.  in 
places  where  there  were  special  hospitals  for  cholera  patients,  the  general 
hospitals,  the  Berlin  C'harite  for  examj^le,  did  not  sulfer  especially.  The 
influence  of  fright  may  be  excluded  from  the  fact  that  in  many  cases  small 
children  and  unconscious  typlioid  patients  were  attacked. 

In  some  cases  medical  attendants  in  hospitals  appear  to  enjoy  a  con- 
siderable degree  of  immunity  from  cholera,  but  on  the  other  hand  not 
a  few  instances  are  on  record  of  exactly  the  opposite.  The  following  ad- 
ditional illustrations,  showing  this  occasional  danger  to  medical  men,  are 
also  furnished  by  Griesinger.  In  Moscow  in  1830,  from  30  to  40  per  cent, 
of  the  hospital  permnnal  suifered  from  cholera,  while  the  rate  in  the  city 
was  only  3  per  cent.  (Jaehnichen).  In  Romberg's  cholera  hospital  in 
Berlin,  in  1831,  of  115  emplo^'ees  in  the  institution,  5-4  had  the  disease;  and 
in  1837,  of  G5  to  70  nurses,  14  (one-fifth)  suifered,  and  at  one  time  7  were  at- 
tacked within  twenty-four  hours.  In  the  Charite  at  Paris,  in  1849,  every 
sixth  man  among  the  employees  Avas  attacked,  while  the  proportion  in  the 
general  population  of  the  city  was  only  one  in  twenty-five.  In  Milan,  in 
1848,  8  out  of  the  16  physicians  suffered  from  cholera.  At  Toulon  in  1832, 
in  the  marine  hospital,  10  out  of  35  of  the  medical  staff  had  the  disease, 
and  5  died;  and  in  the  military  hospital  the  ratio  Avas  8  to  32;  and  of  the 
30  laborers  who  handled  the  dead  bodies,  10  died  within  a  few  days  (Ren- 
aud).  In  Stockholm,  in  1853,  of  the  536  persons  concerned  with  the  care 
of  the  sick,  every  eighth  one  had  the  disease  and  every  sixteenth  died.  In 
Carlscrona,  1  in  5  of  the  nurses  was  attacked  and  1  in  9  died  (Wistrard).  In 
the  Menna  hospital  in  1854,  of  36  nurses,  7  suffered  from  cholera  (2  died), 
3  had  diarrhcea  with  typhoid  symptoms,  and  3  had  cholerine;  and  of  7 
lal)orers  who  carried  the  patients,  every  one  suffered  from  a  debilitating 
diarrhoea  lasting  from  3  to  8  days  (C.  Haller).  In  the  Strasbourg  hospi- 
tal in  1849,  5  of  the  10  nurses  were  attacked,  and  in  1854,  3  out  of  10 
(Reuss).  These  figures  show  that  at  times  the  sickness  of  the  medical 
2)ersonm'l  is  not  inconsiderable.  The  variations  in  the  proportion  of  hos- 
pital attendants  attacked  were  due  to  the  different  degrees  of  cleanliness 
observed.  Sometimes  great  care  was  observed  in  quickly  removing  and 
disinfecting  the  intestinal  discharges,  and  at  other  times  great  laxity  pre- 
vailed in  this  regard.  But  it  is  not  surprising  that  the  physicians  are  less 
liable  to  suffer  than  are  the  nurses  and  the  other  patients,  since  the  former 
remain  but  a  short  time  with  the  sick  and  have  nothing  to  do  with  the 
discharges,  or  at  least  examine  them  only  in  a  fresh  state.  The  same  fact 
is  observed  in  t}^3lioid  fever,  that  the  medical  attendants  are  much  less 
likely  to  suffer  than  are  the  patients  living  in  the  same  ward  with  the  ty- 
phoid patients. 

Again,  from  a  study  of  the  observations  recently  made  in  the  Trench 
epidemics.  Dr.  H.  Mireur '  formulates  the  following  propositions  concern- 
ing the  contagiousness  of  cholera: 

1.  Cholera  is  not  transmitted  directly  from  the  sick  to  the  well  either 
by  contact  or  through  the  respiratory  passages.  2.  The  i:)roducts  emanating 
from  cholera  patients,  the  dejections  and  vomited  matters,  contain  a  germ 
Avliich  is  not  immediately  transmissible  by  itself,  but  which,  placed  under 
favoring  conditions,  gives  rise  to  a  contagious  principle — the  cholerigeuous 

'Op.  tit.,  ]).  154. 


THE  COMMUNICABILITY  OF  CHOLERA.  205 

principle.  3.  The  contagion  of  cholera  is  never  operative  but  through 
this  principle,  either  through  the  medium  of  the  atmosphere  or  of  water: 
4,  Clothing  and  merchandize,  much  more  than  individuals,  are  the  agents 
for  the  transportation  of  this  principle.  5.  The  cholerigenous  principle 
is  implanted  only  in  those  natures  in  some  sort  prepared  to  receive  it;  and 
it  produces  either  cholera  or  cholerine  according  as  the  soil  which  it  meets 
is  more  or  less  favorable  for  its  development;  when  the  soil  is  unfavorable 
no  result  is  produced. 

This  subject  is  sufficiently  important  to  warrant  the  introduction  of 
the  following  additional  evidence,  illustrating  the  point  in  question. 

According  to  Read — 

In  Constantinople  no  less  than  twenty-seven  physicians  and  medical  assistants 
were  attacked  and  died  during-  tlieir  attendance  ou  cholera  patients;  and  in  Paris 
and  Toulon  similar  results  followed.  At  Halifax,  X.  S.,  two  of  the  physicians 
who  volunteered  in  aid  of  the  steamer  England,  whieli  put  in  there  disabled  by 
the  ravages  of  cholera  among  the  officers  and  crew,  as  well  as  among-  the  steerage 
passengers,  took  the  disease,  and  one  died. 

Again : 

Of  one  hundred  and  thirty-nine  physicians  engaged  in  attending  cholera  pa- 
tients in  Naples  under  the  White  Cross  Society',  twenty  died. 

From  the  London  Hospital  Reports,  vol.  iii.,  we  learn  that 

In  1833  the  cases  of  cholera  in  Edinburgh  were  in  the  proportion  of  1  to  every 
1,200  of  the  population  of  tlie  city,  while  among-  those  in  attendance  upon  the  sick 
the  proportion  was  1  to  5.  In  1848-49  one-fourth  of  tfie  nurses  employed  in  the 
cholera  hospital  took  the  disease,  while  in  the  general  hospital,  onl3'  a  few  jjaces 
distant,  where  no  cholera  patients  were  received,  not  a  single  attendant  was  at- 
tacked. In  the  London  Hospital,  in  1866,  none  of  the  medical  officers,  volunteer 
nurses,  or  sisters  were  attacked.  Of  the  (regular)  nurses,  five  contracted  the  dis- 
ease, and  of  these  four  died. 

Stille  also  alludes  to  the  severe  and  fatal  epidemic  which  in  1849  broke 
out  in  the  Philadelphia  Almshouse:' 

The  resident  physicians  of  the  hospital  were  abundantly  occupied  with  the  care 
of  the  sick  of  other  diseases,  and  it  was  thought  prudent  not  to  allow  any,  even 
an  indirect,  communication  between  them  and  the  cholera  patients.  The  latter 
were  tlierefore  removed  to  an  isolated  building  in  the  middle  of  the  quadrangle, 
and  attended  by  physicians  from  the  city  wiio  had  volunteered  their  aid.  Three 
or  four  of  these  physicians  had  attacks  of  cholera,  and  two  of  them  died.  At  this 
time  there  was  no  cholera  at  all  in  the  city,  and  the  young  physicians  could  not 
liave  become  infected  outside  of  the  almshouse.  Thej-  were  attacked  while  at- 
tending the  sick  of  cholera,  but  the  regular  house  physicians,  who  seldom  visited 
the  cholera  patients,  escaped  altogether. 

In  an  able  article  on  the  germ  theory  of  zymotic  diseases,  Dr.  "\V.  B. 
Carpenter  ^  makes  some  comments  that  may  also  prove  of  interest  in  this 
connection.     He  says: 

The  conditions  of  the  spread  of  typhoid  or  enteric  fever  are  closeh*  analogous 
to  those  of  the  diffusion  of  cholera;  and  the  doctrine  of  disease-germs  proves  as 
satisfactorilv  applicable  to  the  one  case  as  to  the  other. 

But  because  typhoid  germs,  when  introduced  into  the  himian  system,  breed  and 
multiply  within  it,  and,  when  voided  ft-om  the  intestine,  may  be  conveyed  bj'  the 
water  into  which  they  have  found  their  way  into  the  bodies  of  other  persons,  who 
then  become  the  subjects  of  the  disease,  it  by  no  means  follows  that  the  human 
body  is  their  only  breeding-ground,  or  that  water  is  their  only  vehicle.  On  the 
conti-ary,  those  who  have  most  carefully  studied  the  subject  are  now  generally 

'  Philadelphia  Medical  Examiner,  November,  1849. 
=*  The  Nineteenth  Centurv,  Februarv  1884. 


2Q(3  ASIATIC  CHOLERA 

agreed,  that  when  typhoid  germs  liave  been  discharged  into  sewers,  tliey  not  only 
infect  their  contents,  but  so  develop  themselves  under  lavoring  conditions  (es])e- 
cially  warmth,  stagnation,  and  seclusion  from  tlie  air)  as  to  give  rise  to  an  enor- 
mous increase  of  the  contagium.  And  in  the  case  of  the  wide  diffusion  of  typhoid 
poison  by  milk,  it  seems  far  more  probable  that  the  germs  introdviced  by  the  con- 
taminated water  used  in  washing  the  milk-vessels  have  multiplied  by  self-develop- 
ment in  the  milk  put  into  them,  than  that  tliey  should  have  originally  been  abun- 
dant enough  to  communicate  the  disease  to  so  large  a  number  of  individuals  as 
are  in  some  instances  attacked  by  it. 

He  sums  up  his  opinioiis  touching  the  contagion  of  cholera  in  the  fol- 
lowing way: 

On  the  whole,  then,  the  conclusion  seems  clear,  that  while  the  breeding  ground 
of  ordinary  malarious  germs  is  the  eartii  alone,  and  the  breeding  ground  of  tlie 
germs  of  flie  ordinary'  exanthemata  is  the  iuunan  body  alone,  there  is  an  inter- 
mediate class  of  pestilential  diseases — including  cholera,  t^'phoid,  and  i)robably 
yellow  fever — in  which  (as  Mr.  Simon  '  tersely  expressed  it)  "certain  microphytes 
are  capable  of  thriving  eqvially,  though  perhaps  in  different  forms,  either  within 
or  witiiout  the  animal  body;  now  fructifying  in  soil  or  waters  of  appropriate  qual- 
ity-, and  now  the  self-multiplying  contagium  of  a  bodily  disease." 

But  although,  as  has  been  shown,  the  evidence  in  favor  of  supposing 
that  cholera  does  not  enter  the  liuman  system  through  the  respiratory 
passages  is  decidedly  strong,  and  although  it  is  reasonable  to  believe  that 
the  specific  infection  must  always  occur  through  the  alimentary  canal, 
Carpenter  nevertheless  holds  that  a  primary  introduction  of  disease- 
germs  into  the  lungs   may  occur  in  cholera.     He  says: 

The  doctrine  that  the  disease-germs  of  cholera  and  typhus  breed  in  the  human 
intestine  o)iIy,  and  that  thej^  are  introduced  into  it  by  water  alone,  obviously  sets 
at  nauglit  a  large  proportion  of  those  precautionary  measures  on  which  those  who 
are  most  practically  conversant  with  the  subject  lay  great  stress.  Everything 
ought  vmquestionably  to  be  done  to  preserve  our  domestic  water-supply  from  con- 
taiuination,  as  well  as  to  secure  the  purity  of  its  sources;  and  to  disinfect  not  only 
tiie  intestinal  dejecta  of  patients  affected  with  cholera  or  typhoid,  but  everything 
contaminated  by  tliem.  But  we  ought  not,  in  doing  these  things,  to  leave  others 
undone;  and  all  experience  justifies  tlie  emphatic  warning  of  tlie  Local  Government 
Board,  as  to  the  danger  of  breathing  air  which  is  foul  with  effluvia  from  the  same 
sorts  of  impurity — a  danger  whose  source  obviously  lies  in  the  atmospheric  trans- 
portation of  disease-germs. 

There  are  obvious  objections  to  the  acceptance  of  these  views,  in  so 
far  as  they  relate  to  aerial  infection.  In  the  first  place  neither  Koch's 
bacilli  nor  any  other  bacteria,  barring  the  ordinary  atmospheric-microbes, 
are  discoverable  in  the  lungs  of  cholera-bodies. 

Again,  even  supposing  that  through  a  contaminated  and  germ-carrying 
atmosphere  a  deposition  of  microbes  occurs  in  the  upper  air  passages, 
they  may  nevertheless  be  carried  into  the  alimentary  canal  through 
deglutition.  And  finally  it  should  never  be  forgotten  that  the  primary 
lesions  of  cholera  are  intestinal,  and  not  pulmonary.  So  that  whatever 
potency  Ave  may  wish  to  ascribe  to  foul  air  as  a  predisposing  factor  in  the 
production  of  cholera,  we  must  insist  that  the  actual  infection  has  not 
iDeen  shown  to  take  place  through  the  respiratory  channels. 

Surgeon-General  Murray,'  Avho  served  for  many  years  (38)  in  India, 
ordered  about  500  circulars  to  be  sent  to  the  local  governments  and  their 
medical  officers.  From  the  returns  thus  received  it  became  evident  that 
there  was  an  almost  unanimous  belief  in  the  communicability  of  cholera. 

•  Article  "  Contagion  "  in  Quain  s  Dictionary  of  Medicine. 
-  The  Practitioner,  vol.  xix. 


THE  C03IMUXICABII,ITY  ,0^   CH0L|:RA.  9()J 

Those  wlio  believed  m  a  spread  from  pers^ii  to  person  amounted  to  75 
per  cent,  of  the  whole  nnmher:  from  place  t<J  place.  85  per  cent. ;  by 
the  evacuations.  92  per  cent. ;  and  by  clothing,  as  many  as  98  per  cent. 

In  our  own  country  the  history  of  the  epidemic  in  1873  furnisliesa 
multiplicity  of  examples,  illustrating  the  contagious  character  of  .iVsiatic 
cholera.  Biit  it  is  not  intended  to  weary  the  reader  with  further  details. 
In  the  light  of  previous  experience,  in  the  light  of  recent  researches,  in 
the  light  of  the  matured  opinions  of  the  majority  of  accurate  observers, 
we  must  proclaim  the  contagiousness  of  epidemic  cholera.  And  it  may 
be  proper  to  point  out  that  in  this  respect,  if  in  no  other,  the  disease 
differs  radically  and  completely  from  its  symptomatic  ally  cholera-morbus. 


208  >j.V^^    ASIATIC  CHOLERA. 


..vV^ 


CHAPTER  XXVI. 

CONDITIONS  WHICH   FAVOR    THE    ORIGIN  AND    DISSEMINATION    OF 

CHOLERA. 

It  seems  necessary  to  state  explicitly  tliat  whether  Ave  accept  the  doc- 
trine of  the  parasitic  origin  of  cholera  or  not,  we  must  still  recognize 
certain  secondary  causes  favorable  to  its  breaking  out  and  propagation. 
It  will  be  our  duty  now  to  examine  some  of  these  favoring  conditions, 
which  are  much  less  in  dispute  than  the  immediate  exciting  cause  of  the 
disease,  although  Avriters  are  by  no  means  agreed  in  ascribing  the  same 
amount  of  potency  to  the  different  agencies  in  question. 

The  whole  history  of  cholera  shows  it  to  be  emphatically  a  disease 
spread  by  human  intercourse.  It  does  not  travel  quicker  by  land  or  water 
than  man.  Nor  does  it  spread  in  directions  unknown  to  commercial  or 
military  movements. 

Oa  land  it  has  usvially  crept  from  place  to  place,  and  if  sometimes  it  lias 
seemed  to  leap  across  wide  spaces,  and  even  seas  and  oceans,  it  has  never  inviiiled 
any  inland  town  or  seaport  without  having  been  brought  tiiitlier  from  a  point 
already  attected  with  the  disease.  Nor,  having  once  entered  an  inland  or  seaboard 
town,  "does  it  spread  equally  therein  in  all  directions,  but  prevails  chiefly  in  the 
quarter  immediately  surrounding  the  place  of  its  entrance.  If  appropriate  sani- 
tary measures  are  enforced,  it  is  sometimes  confined  to  that  cjuarter,  and,  in  tlie 
case  of  quarantine  stations,  it  has  repeatedly  been  prevented  from  extending  be- 
yond them.  This  statement  may  be  illustrated  by  the  fact  that  of  fourteen  epi- 
clemics  of  cholera  at  Staten  Island,  the  quarantine  station  of  New  York,  all  but 
four  were  prevented  from  reaching  that  city.'  When  the  disease  does  overleap 
the  barrier  opposed  to  it,  its  origin  and  subsequent  course  can  usuallv  be  traced 
(Stille). 

It  goes  without  saying  that  the  individual  may  become  more  or  less 
predisposed  through  his  circumstances  in  life,  his  personal  habits,  and  his 
surroundings.  But  the  causes  operative  in  this  respect  are  the  same 
deleterious  influences  favoring  the  acquisition  of  all  other  infectious  and 
preventable  diseases. 

Poverty,  with  its  incidental  conditions  of  bad  air,  filth,  overcrowding, 
intemperance  and  other  excesses,  doubtless  favor  the  acqtiisition  of 
cholera,  but  acting  independently  of  the  specific  poison  of  the  disease,  they 
are  utterly  impotent.  The  relative  mortality  from  cholera  is,  therefore, 
not  more  excessive  among  the  poor  and  shiftless  than  that  of  other  diseases 
fostered  by  unhygienic  living  and  the  weakening  effects  of  insutficient  or 
improper  food  and  air. 

As  regards  the  sex  of  individuals,  it  does  not  seem  that  one  is  more 
liable  to  take  cholera  than  the  other. 

'  Petei-s'  Notes,  3d  ed. ,  p.  94. 


CONDITIONS  FAVORABLE  TO  CHOLERA.  209 

Age  is  of  greater  importance  than  sex.  The  liabilit}-  to  fatal  attacks 
increases  after  45  in  a  very  decided  manner.  In  England,  according  to 
Gull,  the  greatest  fatality  occurred  under  one  year  and  over  fifty-iive,  Tlie 
liability  to  contract  the  disease  appears  to  be  greatest  between  the  ages  of 
15  and  40,  and  it  is  noteworthy  that  the  relative  mortality  is  the  sliglitest 
for  about  the  same  period.  Infants  under  one  year  of  age  are  not  spe- 
cially prone  to  acquire  cholera,  but  when  they  do  take  the  disease,  the  result 
is  almost  invariably  fatal. 

Occupation  does  not  appear  to  influence  the  liability  to  cholera. 
In  a  general  way,  of  course,  unhealthy  and  very  fatiguing  work  by  weak- 
ening the  system  renders  it  more  liable  to  the  inroads  of  disease.  But 
this  does  not  apply  especially  to  cholera. 

Habits, as  already  intimated,  may  influence  the  susceptibilitvto  cholera 
in  a  more  or  less  pronounced  way.  It  is  held  by  writers  that  habitual 
drunkards,  before  the  stage  of  organic  visceral  changes,  are  no  more  prone 
to  the  disease  than  the  temperate.  Indeed,  it  is  supposed  by  some  authors 
that  habitual  drunkards  belonging  to  the  better  classes  enjoy  a  relative; 
immunity  from  the  disease,  on  account  of  their  avoidance  of  water  that 
may  have  become  contaminated.  The  weight  of  evidence,  however,  favors 
the  opinion  that  alcoholic  drinks  may  assist  the  production  of  cholera. 

It  was  found  that  during:  the  cholera  epidemic  of  1848-9  in  England  the  deaths 
from  cholera  on  Saturday,  Monday,  Tuesday  and  Wednesday  wei-e  above,  and  on 
Thui-sday,  Friday  and  Sunday',  below  the  average.  The  weekly  wages  are  gener- 
ally paid  on  the  Saturdays,  and  tlie  Mondays  in  London  and  other  cities  are  days 
on  which  a  certain  proportion  of  the  population  indulge  in  intoxicating  drinks. 
During-  the  epidemic  of  1865  tlie  mortality  in  Berlin  suddenly  rose  on  certain  days, 
and  was  clearly  referable  to  excess  in  drinking.  In  1866,  Dr.  Andrew  Clark  stated, 
in  respect  to  the  London  Hospital,  that  immediately  after  pay-day  among  work- 
men there  was  a  great  influx  of  cholera  patients.  When  the  epidemic  of  cholera 
broke  out  at  Naples  in  tlie  beginning  of  September,  the  Pungola,  a  Neapolitan 
newspaper,  attributed  the  increased  number  of  cases  to  intemperate  living-  on  the 
olst  of  August,  which  was  a,  fete  day  (Chapman). 

In  an  interesting  article  on  the  germ-theory  of  zymotic  diseases,  Dr.  AV. 
B.  Carpenter'  makes  the  following  allusion  to  alcoholic  excesses: 

The  experience  of  cholera-epidemics  has  presented  numerous  examples  which 
testify  to  the  evil  results  of  intemperance;  but  I  know  of  no  case  in  which  the 
benelits  of  extreme  temperance,  in  keeping"  at  bay  the  operation  of  a  zymotic  poi- 
son, were  more  remarkable  than  in  the  contrast  between  the  march  of  the  84th 
Regiment  (of  which  Dr.  E.  Parkes  was  at  that  time  assistant-surgeon)  from  Madras 
to  Secunderabad,  in  1847,  and  the  concurrent  march  of  the  63d  Regiment  from 
Secunderabad  to  Madras.  Tlie  former  had  been  previously  quartered  for  several 
months  in  healthy  barracks;  a  large  number  of  men  were  total  abstainers,  while 
the  rest  were  very  temperate;  and  their  death-rate  had  been  no  more  than  12.1  in 
1,000  per  annum.  The  latter  had  been  overcrowded  in  the  barracks  at  Secundera- 
bad; though  not  specially  intemperate,  they  habitually  indulg-ed  in  alcoholics,  and 
their  death-rate  had  been  78.8.  The  two  marches  were  made  at  the  same  time,  in 
opposite  directions,  in  a  very  wet  and  unhealthy  season,  thi-ough  a  country  in- 
fested with  cholera  and  fever;  and  while  the  84th  was  almost  entirely  free  from 
these  diseases,  the  63il  had  so  many  sick  when  the  two  regiments  crossed  on  the 
road,  as  to  be  obliged  to  borrow  the  84tli's  sick-palanquins. 

Now  since,  in  both  these  cases,  the  infecting  cause  must  have  operated  alike 
on  all,  it  is  clear  tliat  in  whatever  way  the  cholera-germs  are  received  into  tlie 
human  body,  it  is  on  the  previous  condition  of  each  individual  that  their  potency 
depentis,  and  that  this  condition  is  induced  by  any  cuuses  which  engender  in  this 
circulating  flvxid  a  suitable  jJot»(tZ« Hi  for  their  growth  and  multiplication. 

Dissohite  habits  generally,  venereal  excesses,  uncleanliness,  do  not  ap- 

'  Nineteenth  Century  Review.     February,  1884. 
14 


210  ASIATIC  CHOLERA. 

pui'ently  invite  cholera  in  a  more  marked  degree  than  they  do  other 
diseases.  But  their  pernicious  influences  on  the  mortality  of  those  attacked 
is  undoubted. 

Dr.  McClellan  says  in  this  connection:' 

During-  an  epidemic  of  cholera,  it  is  particularly  those  whose  systems  are  irri- 
tated by  other  diseases;  those  who  are  suffering-  from  depression  of  the  nervous 
forces  from  any  cause,  but  especially  that  which  attends  excessive  fatigue,  fear, 
or  debauches;  those  who  live  in  open  violation  of  all  hygienic  law;  those  im- 
poverished by  want,  who  are  especially  liable  to  the  disease. 

And  again: 

The  system  of  a  healthy  person  may  resist  the  invasion  of  the  disease,  but  these 
individuals  have  nothing-  to  resist  with,  and  therefore  succumb. 

Writing  on  the  same  subject,  Drs.  E.  and  A.  B.  Whitney^  remark  that : 

The  exhalations  from  low,  moist,  and  marshy  localities,  from  the  offensive  cess- 
pools, water-closets,  sinks,  sewers,  and  the  decomposition  of  animal  and  vegetable 
substances,  from  the  refuse  or  garbage  which  so  often  befouls  the  sidewalks  and 
gutters  of  streets,  are  all  effective,  predisposing  causes  that  directly  facilitate 
the  production  of  the  cholera.  Whatever  tends  to  depress  the  vital  powers,  im- 
pair normal  action,  or  relax  in  any  degree  the  tone  of  the  nervous  system,  favors 
the  operation  of  the  final  cause.  So,  too,  the  low,  vuiderground,  damp,  unventi- 
lated  apartments,  the  crowded  and  uncleanly  tenement  liouses,  in  wliich  multi- 
tudes of  the  poorer  classes  live  in  a  confined,  foul  and  noisome  atmosphei'e,  not 
only  favor  but  actually  invite  the  active  operation  of  the  infecting  agent. 
Habits  of  intemperance,  profligacy,  impurity  and  late  hours  have  a  powerful  in- 
fluence to  depress  and  prepare  the  system  for  an  invasion  of  the  disease  in  its 
most  malignant  form. 

The  Previous  Health  of  individuals  influences  the  mortality  of  an  ac- 
tual attack  more  decidedly  than  the  liability  to  contract  the  disease  in  the 
first  place.  Nevertheless  it  is  obvious  that  all  debilitating  afl'ections  must 
create  a  certain  amount  of  predisposition  to  cholera.  Gastro-intestinal 
disorders  are  particularly  liable  to  invite  an  attack.  On  the  other  hand, 
the  strong  and  robust  are  just  as  susceptible  to  cholera  as  those  of  weaker 
constitution,  unless  the  weakness  have  resulted  from  actual  disease. 

Acclimatization  seems  to  play  a  role  in  the  acquisition  of  cholera.  As 
a  general  thing  those  inured  to  the  variations  of  a  particular  cliinate  are 
less  apt  to  fall  sick  than  the  unacclimatized.  C'Oncerning  residence  in  India, 
however,  Goodeve  says:  ''It  has  been  thought  that  Europeans  of  short  resi- 
dence in  India  were  more  liable  to  suffer  than  those  of  long  residence,  but 
the  opinion  does  not  seem  to  have  been  formed  upon  any  well-ascertained 
facts.  Tlie  committee  on  the  epidemic  of  1861  investigated  the  matter 
for  that  outbreak,  but  they  consider  their  data  too  imjierfect  for  forming 
opinions."  Goodeve  does  not  believe  the  influence  exercised  by  length  of 
residence  in  India  to  be  an  important  element  in  establishing  either  predis- 
position or  immunity. 

But  Fauvel  ^  has  pointed  out  that  in  the  East  Indian  towns  where 
cholera  is  always  endemic,  the  natives  never  die  in  consequence  of  epi- 
demic cholera.  Strangers  and  pilgrims  may,  however,  be  carried  aAvay  in 
large  numbers  by  the  appearance  of  the  disease  among  them.  The  epi- 
demic character  of  an  outbreak  in  any  country  shows  that  the  disease  is  not 
endemic  there. 

'  Cholera  Epidemic  of  1873  in  the  United  States,  Washington,  1875,  p.  47. 
'^  Asiatic  Cholera:  A  treatise  on  its  origin,  pathology,  treatment  and  cure.     By 
E.  Whitney,  M.D.,  and  A.  B.  Whitney,  M.D.,  New  York.     M.  W.  Dodd,  1866. 
■'Bulletin  de  I'Academie  des  Sciences,  1883. 


CONDITIONS   FAVORABLE   TO   CHOLERA.  211 

Psychical  influences  are  of  unquestionable  importance  in  favoring  an 
attack  of  cholera.  Nervousness,  anxiety,  depression  of  spirits,  grief, 
fear,  violent  emotions,  and  even  actual  insanity  would  all  appear  to  pre- 
disi)Ose  the  individual  to  contract  the  disease.  Dr.  Forbes  Winslow  has 
said  that,  ccfteris  paribus,  the  patient  who  has  the  least  fear  of  dying  dur- 
ing an  attack  of  cholera  has  the  best  chance  of  living. 

Apart  from  these  individual  factors,  there  are  a  number  of  other  cir- 
cumstances that  appear  to  facilitate  the  production  and  propogation  of 
cholera. 

Yet  once  more  it  must  be  repeated  that,  while  they  may  impart  energy 
to  the  virulence  of  the  disease  and  favor  its  rapid  spread,  they  have  not  the 
slightest  power  to  produce  cholera  independently  of  the  existence  of  its 
specific  poison. 

General  Atmospheric  Conditions. — Cholera  may  prevail  under  very 
wide  ranges  of  temperature,  humidity  and  barometric  pressure.  Neverthe- 
less a  certain  amount  of  heat,  a  high  atmospheric  pressure,  and  moderate 
humidity  appear  to  favor  the  disease.  In  India  cholera  is  at  its  worst  during 
the  hottest  months,  and  there  appears  in  this  respect  but  little  difference 
between  dry  and  wet  heat. 

In  Calcutta,  however,  Lewis  and  C-unningham  did  not  find  that  tem- 
perature exerts  any  influence  on  the  variations  in  the  prevalence  of  cholera, 
except  in  a  subordinate  way.  For  maximum,  minimum  and  medium 
]3revalence  were  observed  by  them  in  an  almost  unaltered  temperature. 

In  England  (in  1848—49)  the  highest  mortality  occurred  in  September. 
But  in  continental  Europe  cholera  prevailed  extensively  during  the  cold 
weather  of  the  same  year. 

The  association  of  lieat  with  moisture  certainly  favors  the  spread  of 
cholera.  For  example,  Thom.  in  his  report  of  the  violent  outbreak  at 
Kurrachee,  states  that  there  was  a  very  high  dew  point  (83°),  and  a  tem- 
perature of  90°  F.  in  the  shade.  This  led  to  a  sense  of  languor  and  oppres- 
sion, stifled  breathing,  and  great  fatigue  on  slight  exertion. 

Goodeve  states  that: 

A  warm,  moist,  stagnant  atmosphere  in  Bengal,  at  any  time  of  the  year,  is 
often  followed  by  sporadic  cases  of  cholera,  or  by  an  increase  of  cases  where  the 
disease  is  endemic.  Cholera  has  been  known  to  cease  after  heavy  falls  of  rain, 
and,  on  the  other  hand,  to  set  in  immediately  afterward,  as  in  the  Meerut  jail 
in  1861.  In  considering  tlie  influence  of  rain,  we  must  recollect  the  temperature 
prevailing  and  tlie  time  that  has  elapsed  after  the  said  fall.  A  very  few  hours 
after  a  fall  of  even  heavy  rain,  if  there  be  no  wind,  is  sufficient  to  produce  just  tlie 
stag'nant,  hot  and  moist  atmospliere  wliich  is  so  oppressive  to  the  feelings,  and 
favors  so  much  the  spread  of  cholera.  One  must  not  be  naisled  by  the  name  of 
dry  months.  The  hot  months  in  Calcutta  are  called  the  <\ry  months,  and  are, 
indeed,  the  driest  of  the  year,  yet  a  great  deal  of  moisture  exists  dissolved  ni  the 
warm  atmosphere. 

Lewis  and  Cunningham,  who  have  made  quite  an  elaborate  study  of 
the  physical  phenomena  of  India  in  relation  to  cholera,  report  that  there 
is  a  certain  amount  of  coincidence  between  diminished  humidity  and  in- 
creased cholera  prevalence  in  Calcutta.     They  say: 

We  have  maximum  prevalence  and  minimum  humidity  in  March;  and  mini- 
mum pi'evalence  and  maximum  humidity  in  August. 

Witli  especial  reference  to  the  influence  of  rainfall,  these  observers 
state  that  there  is 

nothing  to  justify  the  belief  that  rainfall  in  Calcutta  exerts  any  direct  action  either 


212  ASIATIC  CHOLERA. 

in  producing'  or  diffusing  the  essential  cause  of  cliolera;  but,  on  tlic  other  liand, 
there  is  some  evidence  tiiat  excessive  rainfall  exerts  a  directly  opposite  action. 

It  is  proper  to  point  out  in  this  connection  that  moisture  and  heat 
favor  the  growth  and  development  of  the  comma-bacilli.  And  f nrtlier  that 
a  heavy  rainfall  may  so  dilute  contaminated  pools  and  "wells  as  to  lessen 
the  chances  of  infection.  Still  it  should  not  he  forgotten  that  cholera  has 
been  known  to  speedily  follow  a  severe  thunder-storm. 

The  cessation  of  autumn  epidemics  of  cholera  on  the  approach  of  winter 
is  a  well-established  fact.  Nevertheless  the  disease  may  survive  even  a 
very  cold  winter,  as  has  been  several  times  observed.  Cold  does  not  kill 
the  bacilli  of  cholera,  although  it  appears  to  hinder  their  active  prolifera- 
tion. 

Hirsch  has  found  from  a  study  of  341  outbreaks  in  different  countries, 
that  cholera  has  appeared  in  nearly  half  of  all  the  epidemics  during  the 
summer,  and  chiefly  in  July  and  August.  AViuter  is  characterized  by  an 
unmistakable  exemption  from  the  disease. 

Electricity,  Ozone  and  Cosmical  Influences. — In  spite  of  the  very 
positive  assertions  of  some  writers,  it  does  not  appear  that  either  of  these  fac- 
tors, or  all  combined,  are  decidedly  influential  in  promoting  the  spread 
of  cholera.  But  to  deny  them  all  potency  for  assisting  the  disease  would 
be  to  err  on  the  other  side. 

Mr.  Glai slier  has  made  a  number  of  interesting  observations  touching 
these  points,  which  are  found  in  the  appendix  to  the  Cholera  Keport  for 
1853-54,  and  in  the  report  of  the  Indian  Sanitary  Commission  (18G2). 

In  his  report  on  the  Meteorology  of  London  during  the  three  cholera 
epidemics  of  1833,  of  1848-9,  and  of  1853-4,  he  found  that  they  were 
attended  with  a  particular  state  of  atmosphere,  characterized  by  a  preva- 
lent mist,  thin  in  high  places,  dense  in  low,  during  the  height  of^the 
epidemic.  In  all  cases  the  reading  of  the  barometer  was  remarkably  high, 
and  the  atmosphere  thick. 

In  1849  and  1854  the  temperature  was  above  its  average,  and  a  total  absence  of 
rain  and  a  stillness  of  air  amoiuiting  almost  to  calm  accompanied  the  progress  on 
eacli  occasion.  In  places  near  the  river  the  night  temperatures  were  high  with 
small  diurnal  range,  a  dense  torpid  mist,  and  tlie  air  charged  with  many  impuri- 
ties arising  from  the  exhalations  of  the  I'iver  and  adjoining  marshes,  a  deficiency 
of  electricity,  and,  as  shown  in  1854,  a  total  absence  of  ozone,  most  probably  de- 
stroj'ed  by  the  decomjiosition  of  organic  matter  with  which  the  air  in  these  situa- 
tions is  strongly  charged. 

In  1849  and  1854:  the  first  decline  of  the  disease  Avas  mai'ked  by  a  decrease  in  the 
readings  of  the  barometer  and  in  the  temperature  of  the  air  and  water;  the  air, 
whicii  previoush'  for  a  long  time  had  continued  calm,  was  succeeded  by  a  strong- 
southw-est  wind  Which  soon  dissipated  tlie  former  stagnant  and  poisonous  atmos- 
phere. In  both  periods  at  the  end  of  September  the  temperature  of  the  Thames 
fell  below  60°;  but  in  1854  the  barometer  again  increased,  the  air  became  again  stag- 
nant, and  tlie  decline  of  the  disease  was  considerably  checked.  It  continued,  how- 
ever, to  subside,  altliough  the  months  of  November  and  December  were  nearly  as 
misty  as  that  of  September. 

Soil. — It  has  not  been  conclusively  shown,  although  there  are  very 
positive  assertions  to  the  contrary,  that  the  nature  of  the  soil  has  any  very 
decided  influence  on  the  appearance  and  spread  of  cholera.  But  to  deny 
this  factor  all  importance  would  be  to  err  in  an  opposite  direction.  Accord- 
ing to  McClellan,  stiff  and  clayey  soils  have  shown  a  higher  mortality  than 
loose,  sandy  and  easily  drainable  ground.  Parr  said  that  cholera  was  less 
fatal  in  England  on  primary  geological  formations  than  on  others.  Black 
cotton  soil  was  found  to  exist  in  nearly  half  the  epidemics  examined  by 
Lorimer  (Goodeve). 


CONDITIONS   FAVORABLE   TO   CHOLERA.  213 

Lewis  and  Cunningliam  hold  that  obstructed  ventilation  of  the  soil 
favors  cholera.     They  say  that 

the  tlieory  of  cholera  Avhich  regards  conditions  of  the  soil  as  essentially  determin- 
ing- the  production  of  the  cause  of  cholera  in  a  locality  is  much  more  in  accordance 
with  the  phenomena  of  its  seasonal  prevalence,  as  manifested  throughout  the 
Bengal  Presidency,  than  any  of  the  other  doctrines  appear  to  be. 

Aitken  states  that 

although  very  great  differences  of  opinion  thus  prevail  as  to  the  part  which  obvi- 
ous local  causes  bear  to  the  production  or  spread  of  cholera,  yet  it  is  almost  uni- 
versally considered  that  they  are  necessary  for  the  development  and  propagation 
of  this  disease  in  its  epidemic  forms. 

For  an  analysis  of  Pettenkofer's  views  regarding  the  role  played  by  soil 
and  subsoil  water  in  cholera,  the  reader  is  referred  to  p.  319. 
Lebert  has  pointed  out  that: 

Tlie  geological  structure  of  the  soil  has  of  itself  but  little  influence  upon  the 
disease,  for,  since  Pettenkofer's  reports,  it  is  admitted  that  it  is  the  physical  rather 
than  the  minoi'alogical  structure  whicli  most  concerns  cholera.  Porous  soils, 
which  permit  the  penetration  of  moisture  and  fluids,  especially  facilitate  the  diffu- 
sion of  ciiolera;  while  a  rocky,  solid  subsoil,  immediately  beneath  the  surface,  is 
much  less  suitable.  But  the  porous  condition  alone  is  not  effective  when  it  readies 
to  a  certain  de|>th,  or  wlien  tlie  fluids  traverse  the  soil  so  quickly  that  tliey  can- 
not form  localized  accumulations. 

Elevation  above  Sea  Level. — Lowness  of  site,  all  the  world  over, 
favors  the  appearance  of  cholera.  Farr  says  concerning  London  that  the 
elevation  of  the  soil  lias  a  more  constant  relation  with  the  mortality  of  the 
disease  than  any  other  known  element.  He  asserts  that  the  mortality 
is  in  the  inverse  ratio  of  the  elevation.     Goodeve  remarks  that 

doubtless  this  is  not  from  any  difference  of  barometric  pressure,  but  because 
these  situations  generally  combine  so  many  vinfavorable  sanitary  conditions,  as 
the  moist  subsoil,  tlie  worst  drainage,  the  least  ventilation  and  air  movement,  the 
most  impure  air,  and  the  most  dense  populations. 

It  is  well  to  bear  in  mind,  however,  that  high  mountain  levels  have 
at  times  been  visited  by  severe  outbreaks.  In  India  it  has  been  known  to 
attack  places  like  Kussowlee  (G,000  feet  above  sea-level),  and  Dhurmsala, 
Dajeeling,Jackatalla,  and  Murree  (6,000  to  7,000  feet  high). 

'  Impure  Water. — That  polluted  water,  even  when  not  directly  con- 
taminated by  specific  bacilli,  may  predispose  to  the  acquisition  of  cholera 
seems  self-evident. 

Positive  confirmation  of  the  fact  is  furnished  by  the  observations  of 
Budd,  Acland,  Parkes,  Snow,  Simon,  Farr  and  many  others. 

From  Simon's  report  of  the  last  two  London  epidemics  the  following 
unequivocal  demonstration  of  the  point  under  discussion  is  found:  The 
mortality  among  the  consumers  of  water  supplied  by  two  companies 
presented  enormous  differences.  The  population  subjected  to  this  in- 
voluntary test  amounted  in  round  numbers  to  half  a  million.  The  two 
companies  were 

The  Lambeth  "Water  Company,  which  drew  its  supply  from  the  Thames  at  Dit- 
ton,  above  the  influence  of  the  London  sewage  and  tidal  flux;  and  the  Soutliwark 
and  Vauxhall  Companv,  which  drew  its  supply  from  the  river  near  Vauxhall  and 
Chelsea.  The  water  of  the  Lambeth  Company  was  tolerably  pure;  that  of  the 
Southwarkand  Vauxhall  Company  was  very  impure.  Tlie  water  of  both  compa- 
nies was  distributed  in  the  same  district  at"  the  same  time  and  among  the  same 
class  of  people,  the  pipes  of  tlie  two  companies  being  laid  pretty  evenly  in  the  same 
areas,  in  many  places  running  side  by  side  in  the  same  streets,  and  the  houses  sup- 


2X4  ASIATIC   CHOLERA. 

plied  being  pretty  equally  distributed.  Tlie  deaths  in  the  houses  supplied  by  the 
Lambeth  Company  were  at  the  rate  of  tliirty-seven,  and  in  the  houses  supplied  by 
the  South wark  and  Vauxhall  Company  at  the  rate  of  i:^0  to  every  10,000  persons  liv- 
ing-. It  appears,  therefore,  that  of  the  drinkei-s  of  the  foul  watei%  about  three  and 
a  half  times  as  many  as  tliose  who  drank  the  pm-er  water  died  of  cholera. 

In  the  light  of  Koch's  doctrine  it  may  be  questioned  whether,  among 
other  impurities,  an  admixture  of  specific  microbes  had  not  occurred 
to  make  the  Southwark  water  so  fatal. 

Impure  Air. — Xoxious  effluvia  arising  from  decaying  animal  or  vege- 
table matter,  refuse,  excreta  and  the  like  may  vitiate  the  air  we  breathe 
and  make  it  prejudicial  to  health,  thus  indirectly  inviting  the  spread  of 
cholera.  It  is  not  always  the  most  odorous  emanations,  however,  that 
carry  with  them  the  greatest  danger.  Aitken  justly  says  that  districts  in 
which  "  the  most  putrid  odors  tainted  the  air  have  sometimes  almost  en- 
tirely escaped,  while  others  contiguous  to  them  have  suffered  severely." 

Still  the  delicate  olfactory  organs  may  detect  atmospheric  impurities, 
when  other  means  fail  to  indicate  their  presence.  In  the  city  of  Xew 
York  offensive  odors  have  repeatedly  formed  a  just  cause  of  complaint  by 
private  citizens,  Avithout,  however,  having  led  to  an  abatement  of  the  va- 
rious nuisances  that  spread  their  sickening  stenches  far  and  wide.  Even  if 
the  nose  is  not  the  true  index  of  danger,  it  is  nevertheless  well  to  re- 
member with  Goodeve  that — 

In  spite  of  exceptions,  the  places  in  which  air  is  most  vitiated  from  privies, 
cesspools,  drains,  decaying-  animal  and  vegetable  refuse,  or  from  overcrowding- 
and  concentration  of  human  emanations,  are  those  in  which  cholera  has  generally 
been  most  fatal  and  most  widely  spread. 

Again,  as  long  ago  as  1832  an  English  writer,  Mr.  Orton,'  pointed  out 

that 

an  atmosphere  impi-eg-nated  with  the  products  of  fermenting-  excrement  is  at 
once  the  most  obvious  and  most  constant  concomitant  of  cholera  (the  privy  or  fecal 
contamination  tlieory). 

Such  exhalations^  were  often  found,  even  in  a  concentrated  form,  in  houses 
where  the  existence  of  any  palpable  cause  of  insalubrity  would  scarcely  be  sus- 
pected, and  thus  the  fact  is  in  some  measure  explicable  that  the  pestilence,  some- 
times passing-  over  slums  and  rookeries,  knocked  at  the  door  of  the  comfortable 
annuitant  or  the  wealthy  tradesman.  It  was  found  that  persons  appeared  to  suf- 
fer in  proportion  to  the  contamination  of  the  air  they  breathed  witli  the  privy 
odor,  and  that  immunity  from  this  appeared  to  secure  immunity  from  cholera. 

That  diarrhneal  diseases  are  readily  produced  by  the  emanations  from 
putrid  refuse  is  well  known,  and  as  such  diseases  decidedly  influence  the 
predisposition  to  cholera,  the  importance  of  the  subject  becomes  at  once 
apparent.  Indeed  the  history  of  cholera  abounds  in  so  numerous  and 
such  unequivocal  illustrations  of  this  general  law,  that  it  is  not  necessary 
to  further  dwell  on  the  matter  here. 

Tainted  and  Adulterated  Food.— In  our  age  of  fierce  industrial 
and  commercial  competition,  poisoning  from  adulterated  foods  is  no  un- 
common occurrence.  AVhere  food  has  become  tainted  or  when  it  has  been 
purposely  adulterated,  the  human  organism  will  suffer  in  accordance  with 
the  quantity  of  the  noxious  substances  ingested.  It  is  readily  supposable 
that  this  may  be  so  insignificant  as  to  result  in  no  marked  departure  from 
health,  and  yet  there  may  be  enough  gastro-intestinal  irritation  to  create 
a  predisposition  on  the  part  of  individuals  and  groups  of  individuals  to 
the  acquisition  of  cholera. 

'London  Medical  Gazette,  vol.  x.,  1832,  p.  222. 


EDITOR'S  CONCLUSIONS.  215 

In  the  light  of  Koch's  doctrine  we  must  regard  with  suspicion  any 
cause  that  may  disturb  even  slightly  the  normal  functions  of  the  aliment- 
ary canal.  For  it  appears  that,  in  addition  to  the  introduction  of  specific 
bacilli  into  the  body,  there  should  be  some  departure  from  health  sufficient 
to  produce  a  favorable  soil  for  their  growth  and  multiplication.  That 
tainted,  decaying,  or  actually  putrescent  foods  of  all  kinds  are  in  them- 
selves quite  sufficient  to  induce  choleraic  symptoms  is  a  fact  long  known 
to  the  profession.  And  many  so-called  localized  outbreaks  of  cholera 
have  depended  for  their  origin  upon  some  such  cause. 

Conclusions. — In  spite  of  the  extremely  conflicting  statements  con- 
tained in  the  different  theories  regarding  the  nature  of  cholera,  its  com- 
municability  and  the  mode  of  its  conveyance,  the  writer  holds  that  the  fol- 
lowing points  must  be  regarded  as  facts  proved  to  be  such  by  the  weight 
of  unimpeachable  evidence. 

Cholera  originates  in  India,  where  alone  it  is  now  endemic.  It  is  car- 
ried to  this  country,  and  indeed  to  all  other  countries,  through  no  other 
agency  than  that  of  human  intercourse.  Its  acquisition  includes  the  pos- 
sibility of  direct  individual  contagion,  but  more  particularly  infection  by 
choleraic  fomites. 

The  specific  cause  of  cholera  is  an  organized  body  capable  of  rapid 
multiplication  both  within  and  without  the  human  organism. 

Certain  animals  may  take  cholera,  and  the  disease  is  experimentally 
communicable  to  them. 

While  cholera  does  not  originate  de  novo  in  a  given  locality,  there  are 
nevertheless  certain  general,  local,  and  individual  conditions  that  favor 
both  its  outbreak  and  its  dissemination. 

The  choleraic  virus  acts  first  and  with  greatest  intensity  upon  the  in- 
testinal portion  of  the  alimentary  canal. 

Direct  personal  contagion,  though  not  impossible,  is  a  far  less  frequent 
mode  of  communication  than  indirect  spreading  by  fomites.  The  inter- 
vening agency  of  specific  organisms  is  necessary  even  for  what  we  call 
direct  contagion.  Water  channels,  such  as  rivers,  pipes  and  sewers  are 
very  frequent  carriers  and  disseminators  of  the  infecting  cause.  The  air 
is  only  quite  exceptionally  a  means  of  conveyance,  and  that  only  for  short 
distances. 

The  truth  of  the  above  propositions  cannot  be  gainsaid.  In  the 
opinion  of  the  editor  the  probabilities  are  in  favor  of  a  further  proposition, 
i.e.,  Cholera  is  induced  by  the  entrance  into  the  intestines  of  peculiar 
minute  organisms,  first  accurately  described  by  Koch  and  since  known 
as  comma-bacilli.  The  writer  has  purposely  refrained  from  placing  this 
personal  belief  in  the  same  category  with  the  facts  above  stated. 

From  this  brief  resume  of  the  editor's  views  on  the  causation  of  Asiatic 
cholera,  it  appears  that  our  etiological  knowledge  is  not  as  complete  and 
satisfactory  as  could  be  wished.  But  if  this  be  construed  as  a  reproach 
to  medical  science,  it  applies  with  the  same  force  to  the  etiology  of  other 
infectious  diseases.  Now  far  from  being  discouraged  by  the  insufficiency 
of  what  is  positively  known,  we  should  endeavor  to  turn  it  to  the  best  prac- 
tical account.  And  meantime  further  inquiries  should  be  pushed  dili- 
gently forward,  until  we  may  finally  be  in  possession  of  the  full  truth  re- 
garding the  intimate  nature  of  this  and  other  pestilences. 


PART   THIRD. 


THE    SYMPTOMATOLOGY,   COURSE,    DURATION, 
MORTALITY,  COMPLICATIONS   AND 
SEQUEL.E  OF  CHOLERA. 


BY 


EDMUND  C.  WEISDT,  M.D., 

OF  NEW  YORK. 


CHOLERAIC  DIARRHCEA  AND  CHOLERINE.  219 


CHAPTER   XXVII. 

CHOLERAIC  DIARRHCEA  AND  CHOLERINE. 

General  Remarks. — An  attack  of  Asiatic  cholera  beincr  invariably 
the  result  of  specific  infection,  it  is  but  natural  that  the  disease,  like 
others  belonging  to  the  important  class  of  infectious  maladies,  should  give 
rise  to  symptoms  differing  widely  in  the  degree  of  their  severity.  The 
special  causative  agent  is  the  same  in  kind  always.  But  it  may  find  en- 
trance into  the  system  in  large  or  small  quantity,  the  result  being,  ccp ten's 
paribus,  violent  or  mild  manifestations.  In  addition,  the  usual  modifying 
circumstances  of  acute  disease,  such  as  special  predisposition  or  other 
imperfectly  understood  peculiarities,  will  of  course  influence  to  a  great 
extent  the  gravity  of  the  individual  attack.  Nevertheless  the  essential 
character  of  the  clinical  symptoms  always  remains  the  same.  It  is  readily 
seen  that  in  admitting  the  potent  factor  of  personal  predisposition,  we 
must  be  prepared  to  allow  that  a  small  quantity  of  the  causative  agent 
may,  in  some  cases,  do  as  much  mischief  as  a  much  larger  quantity  would 
create  in  certain  others.  For  wherever  the  particular  condition"  of  the 
person  infected  favors  a  rapid  multiplication  of  the  virus  within  his  body, 
it  is  clear  that  even  an  originally  minute  amount  of  the  same  may  speedily 
assume  very  large  proportions.  But  this  does  not  in  the  least  aff'ect  the 
general  truth  of  the  proposition  made  above  concerning  the  usual  relation 
between  the  quantity  of  specific  poison  introduced  into  the  system  and  the 
severity  of  the  symptoms  that  follow.  For  convenience  of  description, 
it  is  well  to  distinguish  between  three  grades  of  infection  from  cholera, 
namely: — I.  Choleraic  diarrhcea;  II.  Cholerine;  III.  Pronounced 

CHOLERA. 

Before  entering  iipon  a  separate  examination  of  these  three  forms,  the 
editor  would  again  emphasize  the  fact  that  they  constitute  merely  clinical 
types  of  one  and  the  same  disease.  The  division  is,  therefore,  strictly 
speaking,  an  arbitrary  one — a  circumstance  that, when  lost  sight  of,  is  apt  to 
lead  to  confusion. 

Now  Asiatic  cholera  in  its  mildest  form  may  occasion  so  slight  a  de- 
parture from  ordinary  health  that  its  existence,  in  many  cases,  will  hardly 
be  suspected,  and  indeed  clinically  it  easily  escapes  recognition.  In  view 
of  recent  discoveries  it  may,  perhaps,  be  possible  to  positively  diagnosticate 
even  the  mildest  cases  by  a  careful  employment  of  bacterioscopic  methods, 
the  practical  details  of  which  are  fully  explained  in  another  chapter.  But 
the  ordinary  methods  of  clinical  examination  are  inadequate  to  accomplish 
this  object.  It  is  hardly  necessary  to  emphasize  the  importance  of  this 
subject;  for  the  history  of  cholera  abounds  in  unfortunate  illustrations 


900  ASIATIC   CHOLERA. 

of  the  fact  that  even  the  mildest  attack  of  this  disease  may  lead  to  tlie  pro- 
duction in  others  of  decidedly  grave  forms  of  the  affection. 

In  other  words,  fatal  infection  may  be  quite  innocently — becaiise  un- 
wittingly— spread  by  a  person  affected  with  painless  choleraic  diarrhcea. 
Contrast  with  this  exceedingly  mild  manifestation  of  a  specific  infection 
the  gravest  types  of  fully-developed  cholera,  in  which  the  jjoor  sufferer  is 
doomed,  at  the  very  outset,  to  a  speedy  death,  and  we  may  well  stand 
appalled  at  a  scourge  that  can  assume  the  treacherous  guise  of  such  harm- 
lessness,  while  its  true  nature  seems  ever  ready  to  crop  out  in  the  shape 
of  disastrous  epidemics. 

I.  Choleraic  Diarrhoea. — True  choleraic  diarrhoea — that  is,diarrhoea 
dependent  upon  specific  infection,  is  observed  only  during  the  prevalence 
of  an  epidemic.  Scattered  cases  may  of  course  occur  before  the  nature 
of  the  affection  has  been  recognized.  But  the  epidemic  character  of 
cholera,  after  the  disease  has  once  been  imported,  cannot  long  remain 
hidden,  except  when  desperate  attempts  at  concealment  or  misinterpreta- 
tion can  be  successfully  carried  out  by  the  connivance  of  guilty  author- 
ities. 

Choleraic  diarrhoea,  or  cholera  diarrhoea,  has  clinically  no  decidedly 
characteristic  attributes.  It  occurs  suddenly,  as  a  rule,  and  the  dis- 
charges are  copious,  and  often  quite  thin  and  serous.  They  are  generally 
a  little  bile-stained,  and  lose  this  attribute  only  when  increasing  frequency 
of  purgation  occurs.  Ordinarily  the  passages  do  not  exceed  three  or  five 
in  the  twenty-four  hours.  Occasionally,  however,  their  number  is  in- 
creased to  ten  or  twelve.  There  is  diminished  appetite  or  complete 
anorexia.  In  addition,  the  patients  commonly  complain  of  thirst.  Ab- 
dominal rumbling  and  gurgling  noises  are  often  present.  But  as  a  rule 
there  is  neither  colic,  griping,  nor  tenesmus. 

A  slightly  bitter  taste,  perhaps  some  nausea,  general  malaise,  head- 
ache, tinnitus  aurium,  and  occasionally  cramps  in  the  calves  of  the  legs,  in- 
clude about  all  the  subjective  signs  of  this  form  of  the  disease.  "We  find  also 
a  more  or  less  coated  tongue.  So,  too,  a  tendency  to  coldness  in  the  ex- 
tremities may  be  manifested,  but  actual  lowering  of  the  body  temperature 
is  rare,  and  generally  indicative  of  further  mischief.  Slight  febrile  move- 
ments and  sweating  have  been  observed.  A  little  later  a  sense  of 
profound  exhaustion,  out  of  all  proportion  to  the  objective  signs,  may  be 
experienced. 

This  diarrhoea  may  last  from  two  days  to  two  weeks,  and  even  when  it 
does  not  eventuate  in  the  graver  forms  of  the  disease,  it  frequently  shows 
a  tendency  to  relapse  during  the  whole  course  of  an  epidemic,  and  this 
too  in  individuals  neither  previously  nor  subsequently  subject  to  such  a 
disorder.   (Lebert). 

The  specific  nature  of  the  diarrhoea  is  undoubted,  as  shown  by  ample 
experience.  Xevertheless  judicious  treatment  is  potent  for  good,  and  a 
large  proportion  of  cases  make  rapid  and  complete  recoveries.  It  is  in 
the  neglected  cases  that  choleraic  diarrhoea  so  frequently  becomes  the 
precursor  of  the  graver  and  more  fatal  forms  of  the  disease. 

The  importance,  therefore,  of  this  t}-pe  of  cliolera  for  the  individual 
lies  in  the  fact  that  it  is  premonitory  of  danger,  though  not  in  itself  par- 
ticularly dangerous.  And  the  importance  for  the  community  results  from 
the  infectiousness  of  the  dejections,  and  the  possibility  of  a  single  case 
becoming  the  center  of  infection  for  a  large  number. 

From  the  preceding  it  appears  that,   clinically,  simple  and  choleraic 


CHOLERINE. 


221 


diarrlioea  have  so  much  in  common  that,,  as  ah-eady  stated,  a  dinferential 
diagnosis  may  be  impossible  in  a  given  case.  Xor  are  we  helped  over  our 
difficulty  by  observing  that  babies,  the  very  aged,  and  cachectic  or  weak 
persons  in  general,  often  succumb  to  this  form  of  cholera  from  progressive 
exhaustion.  For  it  is  well  known  that  protracted  simple  diarrhcea  mav 
result  fatally  in  persons  belonging  to  one. of  the  classes  just  mentioned. 
But  to  repeat,  if  Koch's  doctrine  is  true,  then  the  detection  by  cultivation 
and  otherwise  of  the  cholera-bacillus  would  remove  all  doubt  from  a  suspi- 
cious case. 

II.  Cholerine. — This  form  of  Asiatic  cholera  differs  but  little  clinically 
from  ordinary  cholera  morbus.  The  arbitrary  boundary  line  separating 
cholerine  from  choleraic  diarrhoea  is  the  occurrence  of  vomiting,  in  addi- 
tion to  the  diarrhoea.  The  latter,  however,  need  not  always  precede 
the  vomiting.  Indeed  Griesinger  states  that  simple  diarrhoea  is  a  precur- 
sor of  cholerine  only  in  a  minority  of  cases — a  statement  which  is  certainly 
at  variance  with  the  observations  of  many  competent  writers.  Cholerine 
begins  abruptly,  as  a  rule.  Several  days  of  languor,  and  vague  uneasiness, 
often  associated  with  loss  of  appetite,  may  precede  it.  Usually  at  night, 
or  toward  early  morning,  the  patient  is  suddenly  attacked  by  purgnig. 
At  first  the  dejections  are  colored  with  bile,  but  they  quickly  lose  their 
bilious  character,  soon  becoming  more  purely  serous,  and  already  show- 
ing a  resemblance  to  the'  characteristic  rice-water  stools  of  pronounced 
cholera. 

The  dejections  of  cholerine  are  more  copious  and  occur  with  greater 
frequency  than  those  of  choleraic  diarrhoea.  Purging  once  established, 
vomiting  does  not,  as  a  rule,  tarry  long.  At  first  only  the  contents  of  the 
stomach  are  ejected,  then  bitter  and  sour,  and  still  later  tasteless,  watery 
fluid  comes  wp.  Marked  debility  with  a  tendency  to  collapse  may  quickly 
supervene. 

The  patients  complain  of  epigastric  pain,  and  often  suffer  from  a  sense 
of  abdominal  pressure.  Griping  occurs,  but  it  is  by  no  means  a  constant 
symptom.  Thirst  may  become  distressingly  intense.  Vertigo  and  tinnitus, 
and  even  S3-ncope  are  apt  to  occur.  Painful  sensations  in  the  muscles  of 
the  legs,  or  actual  cramps,  frequently  arise.  The  countenance  soon  becomes 
altered  giving  the  first  indication  of  the  future  "fades  choler tea."  The 
tongue  is  now  pappy  or  dry.  The  skin  grows  cool,  the  voice  rather  faint  and 
husky.  The  secretion  of  urine  is  more  or  less  diminished,  and  albumen 
may  already  be  present.  If  serous  depletion  still  continues,  in  consequence 
of  the  profuse  gastro-intestinal  transudation,  the  urinary  secretion 
speedily  becomes  almost  or  quite  suppressed. 

Cholerine  is  dangerous  in  proportion  as  its  symptoms  remain  intractable 
and  nidicate  a  seemingly  iiTepressible  tendency  to  run  into  the  last  tyiie, 
that  of  pronounced  cholera.  But,  on  the  whole,  it  may  be  said  that  re- 
covery from  cholerine  is  the  rule.  Convalescence,  however,  is  apt  to  be 
marked  by  relapses,  following  the  least  provocation,  such  as  slight  errors 
of  diet,  cold,  fright,  and  the  like.  This  shows  clearly  enough  the  weak- 
ened and  irritable  condition  of  the  whole  body,  and  more  particularly  of 
the  alimentary  canal. 

Sometimes  a  mild  typhoid  condition  supervenes  to  retard  recovery. 
The  patients  remain  very  weak,  develop  a  slight  febrile  movement,  have 
a  mild  diarrhcea,  with  thirst,  sweating,  coated  tongue,  and  occasional 
albuminuria.  But  even  from  this  somewhat  alarming  condition  complete 
recovery  generally  occurs. 


222  ASIATIC  CHOLERA. 


CHAPTER  XXVIII. 

PRONOUNCED  CHOLERA,  INCLUDING  THE  PRODROMAL  STAGE,  THE 
PERIOD  OF  ATTACK,  AND  THE  STAGE  OF   REACTION. 

The  fully-developed  disease  may  be  conveniently  considered  under 
three  sejiarate  headings,  embracing — A.  The  Prodromal  Stage  ;  B. 
The  Period  of  Attack;  and  C.  The  Stage  of  Reactiox. 

Before  we  proceed  to  examine  the  various  phenomena  of  these  three 
divisions,  it  should  be  stated  that  although  such  a  grouping  is  by  no 
means  unnatural,  yet  the  transition  from  one  stage  of  the  disease  to  the 
following  one  may  occur  by  practically  unappreciable  gradations.  More- 
over, careful  observation  has  shown  that  different  epidemics  exhibit  con- 
siderable variations  in  respect  to  the  manner  of  development  and  the  du- 
ration of  these  different  stages. 

Lebert  justly  says  that  nearly  every  epidemic  has  a  physiognomy  pecul- 
iar to  itself. 

With  regard  to  its  beha^aor  at  different  times  he  writes: '''  It  often  begins 
with  the  lighter  forms  and  then  passes  into  the  graver,  which  may  then 
prevail  to  tlie  end,  but  it  may  also  present  a  high  mortality  from  the  start. 
In  some  cases,  it  is  rather  the  poor,  in  others  all  classes  of  the  population, 
that  are  attacked.  In  many  places  it  lasts  a  few  weeks  or  months,  in 
others  a  year  and  more.  In  medium-sized  or  larger  cities,  in  which  it  has 
already  prevailed,  it  is  but  little  noticed  by  the  majority  of  the  inhabitants; 
while  in  others  it  snatches  away  one-fifth  or  one-fourth  of  the  population, 
spreading  universal  terror  and  horror.  In  the  same  city  we  see  some 
streets  and  public  institutes  more  than  decimated,  while  in  the  neighbor- 
hood the  cheerfulness  and  frivolity,  or  the  work  of  the  inhabitants,  are 
scarcely  interrupted  by  the  individual  cases  of  disease  and  death.  In  the 
sjime  epidemic  there  is  such  a  complexity  in  the  manifestations  and  course 
as  can  scarcely  be  exhibited  in  the  most  faithful  description." 

A.  The  Prodromal  Stage. — This  marks  the  invasion  of  the  body 
by  the  infectious  agent.  Concerning  the  period  of  incubation, Avhich  is  held 
by  different  writers  to  last  from  twelve  hours  to  several  days,  we  have  no 
definite  knowledge.  Frequently  in  a  t3i)ical  attack  of  cholera,  the  patient 
first  experiences  an  undefined  malaise,  his  spirits  are  depressed,  he  feels 
physically  more  or  less  exhausted,  disinclined  to  follow  his  ordinary  occu- 
pation. He  becomes  vaguely  anxious,  irritable,  perhaps  even  a  little  con- 
fused. Einging  in  the  ears,  giddiness,  headache,  epigastric  oppression, 
restlessness,  inability  to  sleep,  may  be  added  to  these  discomforts. 

Griesiuger  also  mentions  a  tendency  to  cold  hands  and  feet,  sensations 


THE  PERIOD  OF  ATTACK.  223 

of  formication  in  the  limbs,  marked  irritability  as  regards  the  sense  of 
hearing,  and  occasionally  audible  abdominal  rnmblings. 

General  and  nervous  manifestations  of  this  kind,  that  probably  already 
depend  upon  the  action  of  the  specific  infecting  matter,  may  be  con- 
founded with  the  consequences  of  fear,  panic,  or  other  physical  disturb- 
ances; neurotic  and  hysterical  phenomena  may  also  result  from  attempted 
fasting,  or  other  revolutionary  changes  in  personal  habits  that  the  timid 
or  ignorant  are  apt  to  undertake  with  the  idea  of  escaping  the  dreaded 
disease.  Generally  all  such  maneuvers,  by  depreciating  the  general  health 
of  an  individual,  have  the  opposite  effect  of  what  was  intended  by  their 
adoption.  Thus  over-cautious  and  nervous  people  of  the  upper  classes, 
as  well  as  the  careless  and  illiterate  of  the  lower  classes,  may  artificially 
engender  in  their  bodies  a  predisposition  to  acquire  a  disease  that  ordinary 
common-sense  measures  might  aid  them  in  effectually  escaping. 

Diarrhoea  may  still  be  absent  at  this  early  period  of  vague  constitutional 
manifestations.  In  not  a  few  cases,  however,  it  precedes  the  symj^toms 
just  enumerated  by  a  measurable  interval. 

The  group  of  morbid  phenomena  described  under  the  heading  of 
choleraic  diarrha:>a  often  marks  the  beginning  of  grave  cholera — a  point 
which  is  of  considerable  importance  in  practice.  There  is  no  regularity 
about  the  order  of  appearance  of  these  various  symptoms,  nor  do  they 
attain  the  same  degree  of  prominence  in  different  cases.  In  a  word,  there 
is  considerable^ variety  in  the  mode  of  onset  of  this  disease — a  circumstance 
that  has  been  already  alluded  to  as  not  devoid  of  significance,  on  ac- 
count of  the  errors  in  diagnosis  to  which  physicians  are  thus  exposed. 

Concerning  this  uncertainty,  Stille  says: 

A  c-urious  feature  of  this  disease  is  that  sometimes  the  onset  even  of  its  graver 
forms  is  not  attended  by  any  evacuations,  although  the  stomacli  and  intestine 
may  be  filled  with  liquid.  It  is  perhaps  chiefly  in  such  cases  that  the  patient  ex- 
periences a  rapid  depression  of  all  the  mental  and  physical  faculties.  The  senses 
are  irritable,  the  head  aches  and  is  confused,  there  is  a  disinclination  to  sleep,  the 
limbs  totter  under  the  weight  of  the  body,  the  pulse  is  frequent  and  feeble,  occasion- 
ally fainting  takes  place:  tlie  skin  is  cool  and  bedewed  with  pei-spiration.  In 
other  cases,  again,  the  attack  is  sudden;  the  patient  is  smitten  with  an  unaccount- 
able feebleness,  speedily  followed  by  profuse  vomiting  and  purging-  and  general 
spasms,  and  dies  without  any  suspension  of  the  sj^mptoms  or  any  tendency'  to 
reaction. 

B.  The  Period  of  Attack. — It  happens  at  times  that  the  prodromal 
stage  is  so  insignificant  in  the  mildness  of  its  symptoms  as  to  be  entirely 
overlooked.  The  patient  is  then  at  once  plunged,  as  it  were,  into  a  sea 
of  violent  and  distressing  manifestations  characterizing  the  period  of  attack. 
It  has  often  received  the  name  of  algid,  cyanotic,  or  asphyxial  stage,  when 
fully  developed.  But  these  terms,  as  also  the  designation  "stage  of  collapse," 
and  all  similar  terms,  appear  somewhat  jjrejudical  and  one-sided.  For 
they  unduly  emj^hasize  a  single  phenomenon  among  several  of  equal  con- 
spicuousness,  rather  than  that  they  serve  to  characterize  the  whole  period 
of  attack,  and  in  this  Avay  this  employment  may  prove  misleading. 

In  some  cases  the  attack  itself  follows  in  the  wake  of  the  more  or  less 
developed  prodromal  symptoms  already  described.  In  others  it  is  ushered 
in  precipitately  without  forerunners.  Its  beginning  in  the  majority  of 
cases  is  observed  at  night,  or  toward  early  morning. 

Copious  Ayatery  purging  of  a  highly  characteristic  fluid  always  occurs. 
Where  no  diarrhcea  has  preceded  the  attack,  the  first  few  stools  are  very 
large,  and  carry  away  the  entire  intestinal  contents  usually  mixed  with 


224 


ASIATIC  CHOLERA. 


bile.  Hence  these  evacuations  may  still  look  dark  and  be  of  pappy  consis- 
tency. 

Very  speedily,  however,  there  begins  a  tempestuous  discharge  of  fluid 
resembling  rice-water  or  whey. 

The  peculiar  appearance  of  these  stools  is  very  characteristic.  They 
are  thin,  pale,  watery,  inodorous,  and  if  there  is  an  abundance  of  floceuli 
and  larger  flakes  they  may  assume  a  somewhat  opalescent  or  milky  as])eet. 
From  their  resemblance  to  water  in  which  rice  has  been  Avashed  or  boiled, 
they  are  by  common  consent  spoken  of  as  the  "  rice-'water  stools"  of 
cholera. 

Now  these  evacuations  are  never  attended  Avith  great  pain;  in  fact,  often 
they  are  absolutely  painless.  Nor  is  there  any  visible  eifort  on  the  i)art 
of  the  patient  to  void  them,  the  thin  fluid  seeming  to  flow  away  from 
him  as  if  poured  from  a  tube  or  vessel.  As  a  rule,  there  is  considerable 
intestinal  gurgling  and  frequent  borborygmi  may  be  heard. 

The  number  of  discharges  is  extremely  variable.  There  may  be  only 
a  few,-  but  often  they  occur  to  the  number  of  fifteen  or  twenty.  A  fair 
average  is  ten.  But  as  many  as  60  have  been  observed  in  the  twenty-four 
hours. 

In  quantity  the  stools  also  show  much  variation.  Ordinarily  a  passage 
amounts  to  four  or  six  ounces,  but  the  patient  may  lose  as  much  as  a  pint 
or  even  a  quart  at  a  time.     The  latter,  however,  is  quite  rare. 

Vomiting,  if  it  has  not  previously  occurred,  is  now  added  to  the  dis- 
tressing symptoms.  At  first  the  contents  of  the  stomach  come  up.  Soon, 
however,  the  ejected  matters  assume  the  same  peculiar  rice-water  or  whey- 
like appearance  which  characterizes  the  fluid  that  escapes  from  the  bowels. 
''  This  fluid  is  ejected  with  considerable  force  from  the  mouth,  as  if  squirted 
out  of  a  large  syringe,  and  each  elfort  of  vomiting  is  followed  by  more  or 
less  exhaustion  to  the  patient"  (Macnamara).  Some  patients,  on  tlie 
other  hand,  vomit  with  apparent  ease,  as  if  there  were  a  simple  overflow 
from  the  mouth,  or  at  most  a  regurgitation,  following  slight  efl'ort.  In 
some  cases  there  occurs,  at  times,  a  gush  of  fluid  simultaneously  from  mouth 
and  bowels.  Along  with  these  "  tempestuous  discharges"  there  are  now 
observed  grave  manifestations  of  other  kinds. 

Thirst,  already  iiitense,  soon  becomes  excessive,  but  all  attempts  to 
quench  it  are  futile,  for  drinks  when  swallowed  are  almost  immediately 
rejected. 

The  secretion  of  urine,  which  before  was  more  or  less  diminished,  is  now 
suppressed.  The  tongue  looks  flabby,  pale  and  thinly  coated.  It  is  pro- 
truded with  difficulty,  and  there  may  be  much  trembling.  General  de- 
bility rapidly  increasing  to  utter  prostration  appears.  Dizziness,  tinnitus, 
palpitations,  a  sense  of  oppression  and  fear,  as  already  stated,  usually  pre- 
cede the  period  of  extreme  exhaustion,  but  in  some  rapidly  fatal  cases, 
they  are  not  pronounced. 

Excruciating  cramps  in  various  muscles,  but  especially  in  the  calves 
of  the  legs,  almost  invariably  set  in,  A  distressing  hiccough  often  tor- 
ments the  sufferer.  The  voice  grows  feeble,  and  on  effort  only  a  husky, 
harsh,  high  tone  is  produced  ( Vox  cholerica). 

The  patient's  general  appearance  likewise  undergoes  a  marked  alteration 
during  this  period.  The  eyes  sink  back  in  their  sockets,  and  assume  a 
vacant,  staring  look.  Dark  wide  areolas  appear  around  the  lids.  The  fea- 
tures shrink,  the  nose  becomes  sharp,  the  lips  thin  and  pallid  the  cheeks 
and  temples  hollow,     A  dusky  hue,  verging  on  cyanosis,  spreads  over  the 


THE  PERIOD  OF  ATTACK.  225 

skin,  which,  also  grows  cold  and  ciammy,  especially  over  the  distal  parts 
of  the  body.  A  little  later  it  becomes  shriveled  as  if  sodden,  and  wrinkles 
spontaneously  appear  at  the  finger  tips.  If  at  this  time  a  fold  is  pinched 
up,  the  loss  of  cutaneous  elasticity  prevents  its  quick  subsidence.  And 
now,  too,  the  temperature  falls.  It  sinks  rapidly  several  degrees,  the  ther- 
mometer registering  d-i°  or  95"  F.  in  the  axilla. 

At  the  same  time  the  pulse  grows  small  and  weak.  It  may  become 
thready,  or  for  a  time  disappear  altogether  from  the  wrist.  In  point  of 
frequency  it  varies  from  90  to  120  beats  per  minute. 

The  breathing  is  short,  shallow  and  hurried.  There  may  be  over 
forty  respirations  to  the  minute,  but  generally  the  number  is  25  or  30. 

The  duration  of  these  symptoms  is  uncertain.  They  may  last  less  than 
one  hour,  endure  a  few  hours,  or  persist  a  whole  day.  A  gradual  abatement 
of  their  severity  may  mark  the  turning  of  the  tide  in  favor  of  ultimate 
recovery.  Unfortunately  this  happens  in  the  smaller  number  of  cases.  In 
the  majority  the  attack  continues  and  all  existing  signs  are  still  intensified. 
The  condition  that  follows  is  often  separately  described  as  characterizing 
the  algid  or  collapse  stage,  or  the  period  of  asphyxia.  But,  as  previously 
stated,  it  properly  belongs  to  the  period  of  attack,  as  the  symptoms  merely 
denote  an  uninterrupted  progression  of  the  disease  from  bad  to  worse. 
Still,  the  fact  is  not  to  be  lost  sight  of  that  death  may  happen  before  and 
recovery  take  place  after  well-marked  collapse. 

To  resume  our  narrative  then,  the  purging  and  vomiting  still  con- 
tinue, but  with  diminished  violence.  The  stools  may  become  slimy, 
frothy,  or  gelatinous,  or  they  may  continue  to  have  a  rice-water  appearance. 

Thirst  remains  intense,  and  the  patient,  if  started  out  of  his  apathy 
through  the  violence  of  the  cramps,  or  when  roused  by  attendants,  is  still 
eager  for  drinks — drinks  that  unfortunately  never  satisfy.  Exhaustion  is 
yet  more  profound,  and  the  patient  sinks  into  a  semi-comatose  condition. 
But  unconsciousness  is  not  developed,  and  he  generally  answers  questions 
intelligently,  though  only  very  languidly  and  in  a  husky  whisper.  AVhen 
not  disturbed  he  lies  on  his  back  motionless,  cold,  inert,  the  ghastly  pict- 
ure of  a  living  corpse. 

Emaciation  rapidly  advances;  the  surface  of  the  body  has  a  leacien 
pallor  or  looks  livid;  the  lips,  nose,  ears,  fingers  and  toe-tips  are  pinched, 
cyanotic,  shriveled.    The  wrinkles  of  hands  and  feet  are  often  very  marked. 

There  is  now  an  icy  coldness  about  the  body,  and  even  the  breath  is 
cool.  The  integument  is  moist  with  a  cold  clammy  sweat.  The  temperature 
may  be  down  to  80°  F.  The  heart  sounds  become  feebler  and  feebler. 
Soon  they  are  scarcely  audible.  The  pulse  has  entirely  faded  away.  Even 
in  the  carotids  or  the  femorals  there  may  be  no  perceptible  beating.  An 
artery  cut  at  this  time  no  longer  bleeds.  From  a  jounctured  vein  dark 
thick  blood  Avill  ooze  slowly,  but  it  does  not  turn  crimson  on  reaching  the 
air.  At  length  circulation  seems  to  have  come  to  a  complete  standstill;; 
the  second  sound  is  no  longer  heard;  even  the  cardiac  impulse  may  cease^ 
to  be  felt.  The  voice,  shoi'tly  before  still  audible  as  a  husky  Avhisper,  is  now 
quite  extinct.  The  countenance  has  grown  intensely  anxious,  or  it  is 
frightfully  distorted.  Hollowness  of  temples  and  cheeks  is  more  conspicu- 
ous than  ever.  The  eyes  have  fallen  back  into  their  orbits  even  more 
deeply  than  before,  the  encircling  areola  is  yet  darker,  deeper,  and  wider. 
The  half -open  lids  reveal  a  dry,  lack-luster  cornea  and  bloodshot  conjunc- 
tivae. About  the  nostrils  and  lips  dry  blackish  sordes  collect.  Here  and 
there  the  icy  surface  is  still  moist  with  viscid  perspiration.  The  urine 
15 


226  ASIATIC  CHOLERA. 

remains  completely  suppressed.  Without  movement,  cold  and  blue,  the 
patient  lies  in  dull  lethargy,  or  death-like  stupor.  And  indeed  the  rapid 
and  labored,  though  shallow  respirations  may  be  the  only  indication  that 
life  still  flickers  in  the  body,  which  by  this  time  may  be  so  wasted  and 
shrunken  that  all  identity  of  person  is  obscured  or  obliterated.  Never- 
theless even  at  this  supreme  crisis  small  stools  may  yet  be  unconsciously 
voided  into  the  bedclothes;  but  most  of  the  transuded  fluid  accumulates 
in  the  bowels.  At  length  the  senses  become  quickly  clouded,  vision  fails, 
breathing  is  slower  and  jerky,  cyan<jsis  spreads  and  deepens,  the  eyes  are 
convulsively  dragged  upward,  coma  becomes  complete,  a  faint  moaning 
may  perhaps  be  heard,  and  death  at  length  mercifully  terminates  the  dis- 
tressing scene. 

The  imperfect  description  just  given  cannot  portray  the  death- 
struggles  that  choleraics  sometimes  pass  through.  But  it  does  not  appear 
necessary  to  dwell  further  on  the  symptomatology  of  these  last  moments. 
One  important  point,  however,  must  still  be  noticed,  namely,  that  when 
anxious  relatives,  experienced  attendants,  and  even  wary  jjhysicians,  have 
given  up  all  hope  of  recovery;  Avhen  the  exhausted  patient,  or  rather  his 
Avasted  body,  lies  in  bed  motionless,  pulseless,  blue,  and  icy  cold,  when 
death  seems  already  to  have  claimed  another  victim,  even  then  the  almost 
incredible  may  happen,  and  a  sudden  favorable  turn  launch  the  poor 
sufferer  forth  upon  the  stage  of  reaction,  culminating  perhaps  in  uninter- 
rupted recovery. 

Thus  it  appears  that  the  same  misleading  uncertainty  marking  the 
earlier  periods  of  an  attack  of  cholera,  may  likewise  be  observed  at  the 
very  end.  And  it  is  this  possibility  of  rapid  change,  a  treacherous  os- 
cillation between  hope  and  despair,  that  at  times  makes  the  disease  so 
painfully  perplexing  to  all  concerned  in  its  management. 

C.  The  Stage  of  Reaction. — Quick  as  was  the  sequence  of  events 
that  seemed  to  conspire  in  hurrying  the  patient  to  his  grave,  just  as  rapid 
may  be  the  turn-about  to  integral  restoration.  Yet  such  a  sudden  change 
is  seen  in  only  exceptional  instances.  As  a  rule,  the  restorative  processes 
appear  gradually  and  continue  to  mature,  as  it  were,  rather  slowly. 
Relapses,  complications,  various  sequels,  are  so  many  stumbling  blocks 
in  the  way  of  smooth,  uninterrupted  recovery. 

Concerning  relapses,  it  is  unnecessary  to  say  anything  further  than  that 
during  the  entire  stage  of  reaction,  even  when  the  patient  seems  already 
quite  out  of  danger,  the  confident  ju'omise  of  his  recovery  may  be  turned 
to  utter  hopelessness  by  a  speedy  return  of  former  symptoms.  Once  more 
the  fickleness  of  the  disease,  as  we  feel  tempted  to  call  this  characteristic 
of  cholera,  appears  in  all  its  delusive  uncertainty.  AYriters  have  attempted 
to  explain  away  this  possibility  of  relapse,  by  calling  it  imperfect  or 
insufficient  reaction.  But  such  pseudo  explanations  solve  no  problems 
and  leave  matters  where  they  were  before.  As  regards  complications 
and  sequelae,  they  will  have  to  claim  our  separate  attention  further  on. 

Simple  reaction,  in  favorable  cases,  is  marked  by  a  return  of  warmth 
to  the  body,  at  first  slight  and  evanescent,  then  more  pronounced,  and 
finally  permanent.  The  heart  sounds  become  again  audible,  and  a  little 
later  pulsation  is  also  perceptible  at  the  wrist.  The  discharges  are  less 
profuse,  or  entirely  checked.  When  they  do  occur,  at  longer  and  longer 
intervals,  they  lose  their  rice-water  appearance,  and  gradually  become 
feculent  and  pappy. 

With  the  return  of  pulsation  and   warmth,  the  cyanosis  also  fades 


THE  STAGE  OF  REACTION.  227 

away.  The  kidneys  slowly  resume  their  function,  though  the  urine  is 
still  albuminous.  Cramps  no  longer  torment  the  patients,  whose  facial 
expression  improves  visibly.  Eespiration  becomes  free,  deep,  and  easy. 
The  voice  regains  its  tone.  For  a  time  thirst  remains  rather  trouble- 
some. Soon  there  is  some  return  of  appetite.  A  natural  calm,  followed 
by  grateful  sleep,  may  occur,  and  complete  convalescence  is  established 
jn  a  period  varying  from  a  few  days  to  several  weeks. 

A  goodly  number  of  cases  do  not  sho^v  this  steady  progress  toward 
recovery.  Circulation  may  seem  unembarrassed,  yet  warmth  does  not 
I'eturn  to  all  regions  of  the  body.  The  distal  parts  remain  cool,  and  even 
the  heat  of  the  trunk  may  again  be  lost.  The  pulse  too  shows  inconstancy, 
wavering  between  strength  with  regularity  and  weakness  added  to  dis- 
turbed rhythm.  Anuria  persists  or  follows  the  first  free  flow  of  urine. 
Diarrhoea  may  remain,  vomiting  recur,  and  troublesome  hiccough  again 
supervene.  The  countenance  is  neither  calm  nor  natural,  the  cheeks 
remaining  hollow,  and  the  eyes  sunken.  Great  restlessness  or  a  tendency 
to  somnolence  is  witnessed.  Respiration,  too,  remains  embarrassed;  and 
while  a  favorable  turn  may  at  any  moment  happen,  the  patients  more 
frequently  jDass  into  a  peculiar  typhoid  condition,  in  which  various  second- 
ary processes  and  complications  arise  that  often  end  in  death.  The  various 
phenomena  that  may  follow  a  typical  attack  of  cholera  will  be  considered 
further  on. 

In  a  small  proportion  of  cases  reaction  may  be  properly  spoken  of  as 
being  excessive.  The  return  of  warmth  is  rapid,  and  well-marked. 
The  face  grows  red,  the  conjunctiva  is  congested,  and  the  eyes  incessantly 
water.  Cardiac  action  becomes  violent,  the  pulses  bound,  a  throb- 
bing headache,  somnolence,  and  perhaps  slight  delirium,  accompany  the 
development  of  a  decided  though  moderately  intense  febrile  movement. 
A  return  of  different  functions  marked  by  profuse  perspiration,  the  passing 
of  a  large  quantity  of  urine,  or  even  the  appearance  of  menstruation  may 
arrest  the  further  development  of  these  symptoms  to  the  typhoid  condition 
already  mentioned.  Excessive  reaction  depends  in  all  likelihood  upon 
various  congestive  conditions  of  internal  organs  which,  when  not  soon  re- 
lieved, assume  the  more  serious  aspect  of  structural  changes.  A  consid- 
eration of  the  latter  belongs  more  properly  to  another  chapter. 


228  ASIATIC  CHOLERA. 


CHAPTER  XXVIIT. 

ANALYSIS  OF  THE  LEADING  SYMPTOMS  OF  ASIATIC  CHOLERA. 

Having  given  an  account  of  the  course  of  events  after  infection  with 
cholera,  sufficient,  it  is  believed,  to  illustrate  the  clinical  history  of  the 
disease,  we  are  now  prepared  to  examine  a  little  more  closely  some  of  its 
leading  symptoms.  In  so  doing  it  appears  advisable  to  take  up  in  orderly 
succession  the  phenomena  belonging  to  the  different  systems  or  organs 
affected  by  cholera. 

The  Organs  of  Digestion. — The  alimentary  canal,  being  most  prom- 
inently concerned  as  regards  the  manifestation  of  morbid  phenomena 
belonging  to  cholera,  will  first  claim  our  attention.  If  there  is  any 
primary  localization  of  the  disease,  it  takes  place  always  in  the  intestinal 
tract. 

Diarrhcea  is  the  chief,  the  most  constant,  and  the  most  characteristic 
symptom  of  an  attack  of  cholera.  It  is  generally  also  the  first  positive  in- 
dication of  existing  disease. 

Even  in  those  rarer  cases  of  extremely  rapid  development,  called 
fulminant  by  the  Germans,  and  foudroyant  in  France,  some  diarrhoea 
either  precedes  vomiting  and  the  other  graver  signs,  or  it  occurs  simul- 
taneously with  them.  The  appearance  of  diarrhoea  as  an  initial  symptom 
finds  ample  illustration  in  the  recorded  experience  of  many  accurate 
observers.  Thus  in  1849  Devillers  reports  that  it  was  present  420  times, 
in  538  fatal  cases.     Briquet  saw  it  145  times  in  188  patients;  Mesnet  in 

1865,  140  times  in  213  cases;  Horteloup,  40  in  100;  Langrone,  49  ir. 
106;  Stoufflet,  343  in  534  (Laveran). 

In  regard  to  the  occurrence  of  ordinary  cholera-diarrhoea  and  cholerine^ 
it  has  been  found  that  different  epidemics  show  considerable  variations. 
Lebert,  who  has  given  special  attention  to  this  matter,  says: 

I  am  inclined  to  believe  that  cases  of  prodromic  cholera  diarrhcea  are  mox'e 
frequent  and  more  widely  diffused  in  malignant  and  extensive  epidemics  than  in 
those  of  less  extent.  In  the  great  Paris  epidemic  of  1849,  which  numbered  about 
ten  thousand  victims,  the  prodromic  diarrlioea  was  absent  in  from  five  to  ten  per 
cent,  of  the  pronounced  cases  of  cholera,  while  I  observed  it  to  be  absent  in  Zurich, 
in  1835,  in  one-third  of  the  pronounced  cases;  and  yet  no  conclusion  could  be  drawn 
from  this  circumstance  as  to  the  course  of  the  disease.  On  the  whole,  prodromic 
diarrhoea  was  absent  in  just  as  many  cases  of  those  who  subsequently  recovered 
as  in  those  who  succumbed  to  the  disease.  I  found  that,  during  the  prevalence  of 
cholera,  the  prodromic  diarrhoea  was  absent  in  seven-eighths  of  the  cases  of  true 
cholerine  (with  colored  stools).  In  Paris,  as  well  as  in  Zurich  and  Breslau,  in 
1866  and  1867,  I  saw  a  number  of  cases  of  diarrhoea  which  were  due  to 
the  influence  of  cholera  recover  without  treatment,  and  without  subsequent 
cholera.     On  the  other  hand,  I  observed,  in  July  and  the  beginning  of  August, 

1866,  such   obstinate   and   violent  cases   of    cholera    diarrhoea   in    the    Breslau 


THE  ORGANS  OF  DIGESTION.  229 

^;aiTison  of  cuirassiers,  where  I  had  chai-ge  of  a  large  ward  of  wounded  patients, 
that  it  required  heavy  and  quickly  repeated  doses  of  opium  to  prevent  an  out- 
break of  cholera.  There  is  no  marked  distinction,  it  is  true,  between  common  in- 
testinal catarrh  and  cholera  diarrhoea,  yet  the  latter  has  many  peculiarities.  Its 
iuception  is  mostly  sudden  and  unexpected,  often  excited  by  colds  or  errors  in  diet. 
Loss  of  appetite,  thii*st,  indigestion,  are  either  absent  or  present  in  only  slight  de- 
gi-ee;  patients  feel  extraordinarily  feeble  and  uncomfortable,  considering  that  the 
diarrhoea  is  neither  frequent  nor  copious.  There  is  nothing  specially  peculiar, 
liowever,  in  the  character  of  the  fluid  stools.  Often  there  are  but  from  one  to 
three  in  the  twenty-four  hours,  during  the  day  or  night,  more  rarely  from  six  to 
eight  or  more;  rvuublings  and  gurgling's  are  very  distressing  to  most  patients.  In 
some  cases  the  diarrhoea  lasts  only  one  or  a  few  days;  in  others,  with  interruptions, 
from  one  to  two  weeks.  In  some  individuals  who  have  not  previously  suft'ered  with 
intestinal  catarrh,  the  diarrho?a  returns  frequently  during  the  whole  course  of  the 
epidemic,  and  then  ceases  entirely  after  it.  Even  in  the  milder  cases  of  cholera  diar- 
rhoea we  sometimes  observe  individual  signs  of  cholera  of  temporary  duration,  as 
suppression  of  urine,  light  cramps  in  the  calves,  colorless,  rice-water  stools,  which 
<'ccur,  however,  more  frequently  in  cholerine.  It  is  not  a  rare  occurrence,  either, 
lor  a  cholera  diarrhtea,  which  remains  in  other  resjaects  without  danger,  to  sud- 
denly increase  in  virulence,  with  violent,  quickly  repeated  stools,  as  in  true  cholera, 
9,nd  yet  cease  quickly  and  be  followed  by  recovery. 

The  copious  stools  of  true  cholera  come  on  suddenly,  and  are  repeated 
at  short  intervals,  the  time  varying  between  ten  minutes  and  two  hours. 
They  may  be  accompanied  or  followed  by  a  little  pain  about  the  umbilicus. 
There  is  no  tenesmus.  In  bad  cases  alvine  incontinence  comes  on  early; 
in  moderately  severe  cases  not  at  all.  Sometimes  the  copious  transudation 
is  retained  within  the  intestines.  At  others  the  blood  speedily  becomes 
so  thick  that  further  transudation  is  impossible.  These  are  very  grave 
cases.  Before  the  first  appearance  of  the  rice-water  stools,  there  often 
occur  a  few  more  or  less  colored  evacuations.  Greenish,  yellow,  brownish, 
even  blackish  and  quite  exceptionally  sanguinolent  discharges  have  been 
observed.  The  rice-water  stools  may  look  like  limpid  water;  more  fre- 
<[uently,  however,  the  presence  of  grayish  shreds  and  flocculi  results  in  some 
turbidity  of  appearance. 

In  quantity  the  evacuations  rarely  exceed  one  pint  at  a  time.  Still, 
€ven  at  this  rate,  it  is  readily  seen  that  six  or  seven  quarts  may  be  voided 
in  24  hours.  The  flakes  and  flocculi  are  composed  of  leucocytes,  detached 
epithelium,  and  mucous  corpuscles.  They  form  a  distinct  sediment  when 
I  ice- water  discharges  are  allowed  to  stand.  Granular  debris  from  the  dis- 
integration of  epithelial  cells  is  also  present  in  great  abundance.  The 
reaction  of  fresh  rice-water  stools  is  always  alkaline.  Generally  they  are 
quite  inodorous.  When  allowed  to  stand,  "the  flocculent  portions,  as  already 
sweated,  sink  to  the  bottom  of  the  vessel,  leaving  a  supernatant  limpid, 
T/hitish  or  gi'ay  fluid. 

Macnamara  states  that  "this  separation  of  the  material  into  two  parts 
takes  place  rapidily  in  many  instances,  say  in  from  one  to  three  hours, 
and  is  evidence  of  the  severity  of  the  disease;  for  if  the  more  solid  matter 
of  the  dejecta  collects  in  the  lower  part  of  the  fluid  very  speedily,  it 
indicates  the  complete  death  and  disintegration  of  the  organic  matter.  On 
the  other  hand,  if  the  separation  of  the  fluid  and  more  solid  components 
takes  place  slowly,  it  is  on  account  of  the  evacuation  containing  a  con- 
siderable quantity  of  comparatively  healthy  mucus,  and  the  case,  so  far, 
allows  of  a  more  favorable  prognosis."  In  spite  of  this  authoritative 
statement,  we  are  not  of  opinion  that  any  reliance  should  be  placed  on  the 
prognostic  value  of  this  simple  test. 

Microscopically  examined,  the  flocculi,  as  already  stated,  are  found  to 


230 


ASIATIC  CHOLERA. 


consist  of  a  conglomeration  of  cells,  showing  more  or  less  disintegration. 
In  addition  masses  of  zoogloea,  and  varions  bacteria  are  present  in  more 
or  less  abundance.  But  although  bacteria  and  various  other  organisms 
have  been  held  at  different  times  and  by  different  observers  to  constitute 
the  exciting  cause  of  cholera,  it  was  not  until  Koch  inaugurated  the  era 
of  pure  cultures  in  solid  media  that  the  subject  suddenly  emerged  from 
the  domain  of  ingenious  speculation  to  enter  the  territory  of  exact  research. 
However  interesting,  therefore,  especially  from  the  historical  standpoint, 
the  views  of  Brittan  and  Swayne,  Klob,  Hallier,  Thome,  Nedswetzky,  Pacini 
and  others  may  be,  Ave  cannot  give  them  space  here. '  Nevertheless  this 
much  may  be  said,  namely,  that  none  of  these  organisms  have  conclusively 
been  shown  to  be  peculiar  to  cholera,  or  to  be  invested  with  powers  of 
specific  infection;  and  that  to  Koch  belongs  the  credit  of  having  found  a 
microbe  that,  quite  apart  from  its  diagnostic  significance,  in  all  probability 
has  a  causal  relation  to  the  disease. 

Examined  chemically  the  stools  are  found  to  consist  mainly  of  a  dilute 
aqueous  solution  of  various  salts,  notably  sodium  chloride,  ammonium 
carbonate,  and  sodium  phosphate.  Potassium  salts  are  either  not  at  all 
present  or  occur  only  in  traces.  The  entire  proportion  of  solid  matters 
varies  between  one  and  two  per  cent.  Albumen  and  other  organic  com- 
pounds are  likewise  found  in  very  small  quantities. 

Parkes  has  examined  the  cholera  discharges  at  different  periods  of  the 
disease.     The  following  table  shows  the  results  of  his  analyses: 

ANALYSES  OF  THE  EVACUATIONS  IN  CHOLERA. 


Period  of  the  Disease  in  which  the  Stool  was 

TAKEN. 


Diarrlioeal  period. 


Early  algid  stage    

Developed  axid  inteuser  algid  stage  . 

Developed  and  moderate  algid  stage 

a  a  n  a  ((  a 

Commencement  of  reaction 

Relapse 


Specific 
Gravity. 


1012.9 


1009.0 
1009.5 


1008.3 

1005.8 

1014.0 

1008.91 

1017.83 


Albumen 

Extract- 

Sol.  Salts 

in  100() 

ine  1000 

in  1000 

Parts. 

Parts. 

Parts. 

0.466 

3.846 

9.04 

0.29 

6.82 

5.99 

2.4 

1.27 

10.98 

1.18 

0.55 

9.14 

2.18 

7.52 

.027  1   2.23 

8.33 

3:2 

5.827 

20.84 

6.34 

1.48 

6.055 

9.085 

0.855 

n.{ 

555 

* 

4.589  1 

3.881 

Total 
Solid  in 
1000  Pts 


13. 9~ 
13.1 
14.65 
10.87 

9.7 
10.83 

8.947 
27.8 
16.62 
18.21 

8.47 


*  Not  weighable. 

On  the  other  hand  Papillon ' 

obtained  the  following 

results  from  twc 

analyses: 

I. 

n. 

Water,  .... 

.     98.13 

97.15 

Amorphous  matter, 
AlkaUne  chlorides. 

.       0.14 
.       0.G9 

■  0.08 
0.85 

Alkaline  lactates. 

0.12 

0.15 

Alkaline  sulphates. 

Phosphates,    . 

Loss,       .... 

.       0.90 

.       0.05 

0.02 

0.94 
0.03 
0.80 

100.00 

100.00 

'  All  the  more  important  observations  germane  to  this  subject  will  be  found  in 
Pai't  II.  of  this  volume. 

-  Journal  d' Anatomic  et  de  Phj'siologie,  Paris,  1865. 


THE  EVACUATIONS  IN  CHOLERA.  2S1 

If  the  stools  are  tinged  with  blood  and  begin  to  have  a  disagreeable  or 
even  fetid  odor  the  prognosis  is  much  more  unfavorable,  than  when  they 
continue  to  be  merely  watery  or  whey-like. 

The  exact  pathological  significance,  or  rather  the  precise  pathogeny  of 
this  copious  and  tumultuous  flux  remains  undecided,  in  spite  of  all  that 
has  been  said  and  written  upon  the  subject.  Probably  it  is  in  a  great 
measure  due  to  the  local  irritation  of  the  specific  infective  agent  of  cholera, 
whether  this  reside  solely  in  the  microbes  or  is  conveyed  by  other  means 
to  the  mucous  coat  of  the  intestines.  But  that  vaso-motor  disturbances 
are  largely  concerned  in  its  production  cannot  be  questioned,  in  spite  of 
the  opposing  vicAvs  of  eminent  writers. 

In  view  of  the  latest  parasitic  doctrine  concerning  cholera,  it  is  decidedly 
interesting  to  remember  what,  years  ago,  was  written  by  Lebert  on  the 
origin  of  the  symptom  under  discussion.  As  the  result  of  an  extended 
experience,  this  careful  observer  says:  "  The  anatomical  changes,  the 
hyperffimia  of  the  mucous  membrane,  the  distention  of  the  mesenteric  veins 
with  thick  blood,  the  ecchymoses  and  hemorrhagic  suffusion  of  the  mucous 
membrane,  the  swelling  and  very  great  softening  of  the  lymphatic  appa- 
ratus of  the  small  intestine,  are,  I  am  convinced,  not  the  cause  of  the 
rice-water  stools,  but  are,  with  the  stools,  the  effects  of  a  vast  development 
of  cholera  germs,  which  intensely  irritate  the  lymphatic  portion  of  the 
small  intestine  and  excite  a  rapid  hypersecretion,  like  poisoning  by  arsenic 
and  other  metallic  salts,  and  like  the  action  of  the  very  severe  drastic 
purgatives.  The  view  defended  by  Griesinger,  that  the  rapid  and  active 
transudation  from  the  intestinal  mucous  membrane  and  the  different 
catarrhal  and  dysenteric  affections  may  be  excited  through  the  condition 
of  the  blood  itself,  has,  it  is  true,  much  in  its  favor;  the  infection  of  the 
foetus  with  cholera  through  the  mother,  for  instance,  lends  it  support. 
But  when  this  author  entirely  rejects  the  local  action  ol  cholera  germs,  he 
goes,  in  this  respect,  I  believe,  too  far." 

And  again,  touching  the  view  which  assumes  that  cholera  is  merely  an 
intense  hydrorrhagia  with  consequent  thickening  of  the  blood,  he  Avrites 
that  it  is  "as  much  strained  as  the  older  neuro-pathological,  electrical, 
and  other  hypotheses."  In  summing  u]3,  the  same  author  says:  "  Much 
obscurity  still  hovers,  however,  over  the  effects  of  cholera  on  the  whole 
organism — an  obscurity  which  can  only  be  cleared  up  by  accurate  clinical, 
histological  and  chemical  analyses.  According  to  our  present  histological 
knowledge,  beside  the  thickening  of  the  blood,  we  find  the  different 
tissues  and  organs  undergoing  degenerative  processes,  which  not  only  pro- 
duce grave  disturbances,  but  also  introduce  into  the  organism  from  the 
degenerated  tissues  injurious  products  of  metamorphosis.  Nothing  is 
more  instructive  in  this  regard,  perhaps,  than  the  tolerably  constant  par- 
ticipation of  the  kidneys  in  the  cholera  process,  and  the  manifold  effects 
resulting  therefrom." 

It  has  been  previously  pointed  out  that  at  times  the  watery  transudation 
is  not  discharged  from  the  bowels.  This  is  quite  probably  due  to  a  par- 
alytic condition  of  the  intestines.  Cases  showing  this  peculiarity  are 
generally  grave,  and  when  death  occurs  the  intestines  are  found  to  be  filled 
with  the  characteristic  fluid.  Formerly  it  was  customary  to  speak  of  cholera 
sicca,  whenever  such  a  condition  was  seen.  More  recently,  however,  the 
term  has  been  given  up,  as  apt  to  convey  the  erroneous  notion  of  a  special 
and  separate  variety  of  choleraic  disturbance. 

The  varying  quality  and  quantity  of  the  fluid  stools  of  cholera  are  not 


232 


ASIATIC  CHOLERA. 


without  practical  importance  as  regards  prognosis.  The  most  favorable 
condition  is  when  they  occur  with  moderate  frequency  and  continue  to  show 
traces  of  coloring  matter,  in  spite  of  their  otherwise  watery  appearance. 
Very  large  stools  are  of  course  unfavorable  on  account  of  tile  severe  drain 
on  the  system  implied  by  excessive  transudation.  In  the  same  way  it  is 
not  a  good  sign  to  witness  a  more  or  less  abrupt  cessation  of  discharges, 
while  the  other  signs  of  the  disease  continue  or  even  grow  worse.  De- 
cidedly bloody  stools  arc  always  ominous.  Early  in  the  disease  they  mean 
intense  hypera^mic  irritation  of  the  mucous  membrane.  Later  they  denote 
various  degenerative  processes  with  necrosis,  ulceration  and  the  like.  In 
almost  all  cases  the  small  intestines  are  the  source  of  whatever  bloody  ad- 
mixture is  observed  in  the  stools. 

Vomiting  is  a  less  constant  symptom  than  diarrhwa,  although  in  the 
great  majority  of  cases  it  soon  follows  the  first  discharges.  Even  when 
vomiting  fails  to  take  place,  the  occurrence  of  nausea  shows  that  the 
stomach  is  at  all  events  affected  by  the  disease-process.  That  stomachic 
digestion  is  early  impaired  or  abolished  is  further  shown  by  those  rare 
cases  where  very  late  vomiting  still  brings  ujd  remnants  of  undigested  food, 
and  again  by  autopsies  in  which  masses  of  ingesta  are  found  almost  un- 
changed in  the  alimentary  canal. 

In  point  of  frequency  the  attacks  of  vomiting  vary  considerably,  occur- 
ring from  ten  to  twenty-four  times  in  as  many  hours,  or  coming  on  only  a  few 
times  throughout  the  entire  course  of  the  disease.  Indeed,  as  previously 
stated,  some  very  grave  attacks  end  in  death  without  vomiting  having  oc- 
curred at  all. 

Initial  vomiting  rids  the  stomach  of  its  contents.  At  first  there  may 
be  painful  gagging,  and  visible  exhaustion  follows  the  act.  Later,  however, 
with  increasing  frequency  of  vomiting  the  fluids  are  ejected  without  ap- 
parent effort. 

They  seem  to  well  up  from  below  by  involuntary  painless  regurgitation 
and  issue  at  the  mouth  in  a  steady  stream.  Less  frequently  they  are  thrust 
out  convulsively  in  interrupted  jets.  The  quantity  of  the  vomitus  depends, 
ccetei'is  pnribui^,  upon  the  quantity  of  fluid  which  is  taken  to  satisfy  the 
patient's  constant  thirst.  But  even  when  little  fluid  is  allowed,  the  copi- 
ous regurgitation  clearly  indicates  that  gastric  as  well  as  intestinal  hydror- 
rhagia  may  take  place  in  cholera.  This  is  further  shown  by  the  investi- 
gations of  Schmidt,'  who  found  urea  and  ammonia  carbonate  in  the 
vomited  matters  of  cholera  patients.  The  character  of  the  ejected  fluid, 
as  previously  pointed  out,  depends  at  first  upon  the  nature  of  the  stomach 
contents.  Soon,  however,  it  assumes  a  distinctly  watery  appearance.  In 
the  limpid  liquid,  flocculi  float  in  greater  or  less  abundance.  In  a  word 
the  vomitus  now  resembles  completely  the  rice-Avater  discharge  from  the 
bowels.  Blood  is  an  occasional  slight  admixture,  but  profuse  gastric 
hemorrhage  is  unknown.  Winge  and  v.  Hunigsberg  have  reported  the 
occurrence  in  rare  instances  of  chocolate-colored  discharges,  simultane- 
ously from  above  and  below. 

Among  1,G00  cases  observed  by  Drasche,  he  failed  to  observe  such  a 
phenomenon  in  a  single  instance. 

The  specific  gravity  of  watery  vomit  may  be  as  low  as  1005,  rarely  it  is 

'  Charalcteristik  der  epidemischen  Cholei'a  gegeniiber  verwandteii  Transuda- 
t  ions  anomalieen.  Eine  physiologisch-chemische  Untersuchung-  von  Carl  Schmidt. 
Leipzig,  1850. 


THE  ORGANS  OF  DIGESTION.  233 

higher  than  1010.  Its  reaction,  as  a  rule,  is  sour,  although  some  observers 
report  to  have  found  it  neutral  or  even  alkaline. 

The  proportion  of  sodium  chloride  is  much  less  than  in  the  alvine 
discharges.  The  presence  of  albumen  is  affirmed  by  Lindsay  and  Heller. 
Schmidt,  on  the  other  hand,  Avas  unable  to  detect  it.  Bile  pigments  in 
small  quantities   are  an   almost  constant  admixture. 

The  sediment  which  the  watery  vomitus  deposits  shows  squamous  epithe- 
lial cells  (rarely  cylindrical  epithelium),  mucous  corpuscles,  granular  debris, 
and  often  fat  droplets.  Lindsay  reports  finding  sarcinte,  the  result  of 
fermentation.  Such  an  occurrence  must  be  quite  rare,  since  the  cholera 
attack  is  usually  of  so  tempestuous  a  character  that  time  for  fermentation 
is  not  provided.  The  finding  of  vibrios  is  likewise  infrequent  and,  as  a  rule, 
denotes  that  decomposition  has  occurred  in  the  fluid  outside  of  the  body. 

A  point  of  considerable  importance,  especially  as  regards  medicinal 
treatment,  is  the  condition  of  the  gastro-intestinal  surfaces  in  relation  to 
its  powers  of  absorption.  Xow  it  is  certain  that  the  assimilative  capacity 
is  ahvavs  much  reduced.  Nevertheless  in  some  cases  it  does  not  seem  to 
be  completely  abolished.  Hiibbenet,'  Duchaussoy,^  Wagner,^  and 
others  have  shown  that  large  doses  of  strychnia,  belladonna  and  other 
2)0werful  drugs  were  inert  when  introduced  into  the  stomach  during  the 
attack,  whereas  injected  into  the  blood,  their  physiological  effects  were 
still  obtained.  But  in  1855  Drasche  instituted  a  series  of  observations 
with  readily  diffusible  substances  such  as  iodide  of  j^otassium.  And  as 
the  result  of  his  positive  experience  he  claims  that  some  absorption  must 
take  place,  even  during  the  period  of  attack. 

Griesinger  has  also  pointed  out  that  ingested  substances  are  by  no 
means  always  recognizable  as  such  in  the  discharges,  having  undergone 
alterations  as  regards  their  color  and  smell. 

On  the  whole  it  seems  that  the  importance  of  tliis  matter  justly  entitles 
it  to  further  accurate  study,  with  the  aid  of  modern  methods  of 
experimental  investigation.  But  this  much  we  know,  namely  that  during 
the  height  of  an  attack,  the  function  of  the  gastro-intestinal  mucosa  is 
so  completely  reversed  that  it  becomes  a  transuding  in  place  of  an  absorp- 
tive membrane. 

The  appearance  of  the  tongue  changes  with  the  development  of  the 
different  stages  of  an  attack.  Being  less  an  index  of  the  state  of  the 
digestive  organs  than  a  result  of  the  patient's  general  condition,  which  is 
better  judged  from  other  symj^toms,  it  follows  that  no  great  weight  at- 
taches to  lingual  appearances.  Participating  in  the  changes  of  other  distal 
organs,  Ave  find  it  growing  cold  and  blue,  or  even  blackish  as  the  attack 
advances.  Flat,  flabby,  moist  and  coated  Avith  a  moderately  thick  layer 
of  grayish  material,  in  the  earlier  stages,  it  becomes  cleaner,  and  appar- 
ently smaller  later  on.  "When  a  typhoid  condition  develops,  it  groAvs  dry, 
and  parched,  its  color  changing  to  red  or  brown,  and  crusts  appearing  on 
its  surface. 

AVhile  the  ap2)etite  may  remain  unchanged  in  the  prodromal  period, 
complete  anorexia  characterizes  the  fully  developed  attack.  When  ques- 
tioned, patients  complain  of  a  bad  taste  in  the  month,  but  voluntary  state- 
ments regarding  its  presence  are  rarely  made. 

It  is  quite  different  Avith  regard  to  thirst.     This  is  one  of  the  most  con- 

'  Bericht  iiber  die  Cholera,  etc.     Berlin,  1848. 

^Gazette  des  liopitaux,  1854 

3  Schmidt's  Jahrbikher,  vol.  88,  p.  249. 


234 


ASIATIC  CHOLERA. 


stant  and  troublesome  symptoms,  as  well  as  one  of  the  earliest  and  most 
persistent.  The  poor  sufferers  crave  cold  drinks  to  satisfy  their  sense  of 
internal  heat.  Fluids  are  eagerly  swallowed  only  to  be  immediately  re- 
jected. Vomiting  again  intensifies  thirst,  and  a  pitiful  circnhts  vitiosns 
may  thus  be  inaugurated.  Even  during  the  period  of  convalescence  thirst 
may  long  remain  as  a  troublesome  accompaniment  of  gradual  restoration. 
Of  course  the  immense  drain  of  water  through  the  copious  intestinal  flux 
is  accountable  for  the  intense  thirst  of  cholera  patients.  In  profuse  hemor- 
rhao-es,  it  is  well  known  that  excessive  thirst  forms  a  characteristic  phe- 
nomenon. 

The  Abdomen. — At  the  commencement  of  an  attack  many  patients 
complain  of  griping  or  colicky  pains.  The  abdomen  may  be  quite  tender  to 
the  touch  and  more'or  less  firmly  retracted.  Later  on  the  muscles  relax  and 
a  Shabby,  doughy  condition  develops.  Palpitation  then  readily  reveals  the 
presence  of  gurgling  fluids.  Succussion  sounds  may  be  loud  and  distinct. 
When  the  patient  suddenly  shifts  his  position,  such  noises  may  be  plainly 
heard  at  some  distance  from  the  bed. 

Singultus  may  occur  at  any  time  during  the  course  of  the  disease,  but 
it  is  most  frequently  observed  in  collapse,  when  it  may  replace  vomiting. 
Though  very  troublesome  it  is  an  unimportant  sign,  and  denotes  merely 
the  participation  of  the  diaphragm  in  the  violent  muscular  contractions 
that  accompany  the  disease. 

Very  soon  after  the  onset  of  profuse  watery  discharges,  decided  changes 
are  witnessed  in  connection  with 

The  Organs  of  Circulation. — Among  the  early  effects  of  cholera 
infection  we  of  ten  notice  violent  palpitation,  accompanied  by  anxiety,  fear, 
and  a  vague  sense  of  distress.  This  soon  gives  way  to  more  positive  signs 
of  disturbed  circulation.  With  advancing  transudation  the  heart's  action 
grows  feeble,  the  apex  beat  is  diminished  or  scarcely  perceptible,  the 
systolic  sounds  may  be  replaced  by  a  faint  blowing  murmur,  and  at  length 
the  second  sound  is  no  longer  heard. 

Pericardial  friction  sounds  have  been  described,  and  accounted  for  on 
the  supposition  of  dryness  of  the  sac.  This  may  appear  plausible  at  first 
sight,  but  the  fact  that  such  sounds  occur  so  rarely  strongly  militates 
against  this  view.  Pericardial  dryness  is  without  doubt  a  constant  accom- 
paniment of  the  excessive  intestinal  transudation  of  cholera.  But  when 
friction  sounds  are  plainly  heard,  they  denote  pericarditis  in  cholera  as  well 
as  in  any  other  disease. 

The  area  of  cardiac  dullness  has  been  repeatedly  found  diminished,  and 
the  inference  drawn  therefrom  that  the  right  side  of  the  heart  becomes 
distended  only  quite  late  in  the  course  of  an  attack.  Indeed  Macnamara, 
in  his  most  recent  publication  on  cholera,'  asserts  the  accumulation  of 
blood  in  the  right  side  of  the  heart  to  be  a  post-mortem  occurrence.  In 
spite  of  this  statement  it  appears  to  be  more  in  accordance  with  analogous 
events  in  other  diseases  to  interpret  this  phenomenon  as  due  to  an  ante- 
mortem  acute  dilatation,  resulting  from  increased  demands  upon  the  work- 
ing force  of  a  much-weakened  dilatable  organ.  On  the  other  hand  it  will 
not  be  disputed  that  dilatation  occurs  rather  late  in  the  course  of  an 
attack  of  cholera.  In  this  connection  it  may  also  be  stated  that  Johnson 
does  not  believe  in  a  cessation  of  circulation  from  cardiac  debility,  as  seen 
for  example,  in  exhaustion.     According  to  him  the  right  side  of  the  lieart 

'  Article  "  Cholei-a,"  in  Quain's  Dictionary. 


THE  ORGANS  OF  CIRCULATION.  235 

becomes  filled  with  blood,  and  circulation  generally  is  impeded  in  conse- 
quence of  a  direct  mechanical  obstruction  of  the  onward  course  of  the 
blood.  The  further  view,  long  advocated  by  him,  that  the  collapse  of 
cholera  as  well  as  the  other  symptoms  of  that  condition  are  due  to  ob- 
structed pulmonary  circulation  from  arterial  spasm  excited  by  the  virus  of 
disease,  he  entertains  to  this  da3^  For  at  the  recent  debate  on  cholera 
before  the  Eoyal  Medical  and  Chirurgical  Society,'  the  presiding  officer 
being  no  other  than  Dr.  Johnson,  he  took  pains  once  more  to  present  an 
array  of  facts  borrowed  from  experimental  physiology  and  a  series  of  argu- 
ments of  a  more  theoretical  nature,  all  of  wliich,  he  held,  distinctly  supported 
Ms  well-known  doctrine. 

The  pulse.  As  a  rule,  jmri  passu  with  the  diminution  of  cardiac 
action,  progressive  changes  are  noticed  in  the  character  of  the  pulse.  At 
first  there  is  increased  frequency,  amounting  to  100  or  120  beats  per  min- 
ute; later  on  the  pulse  may  run  down  to  90  or  even  80;  still  later  it  gener- 
ally rises  again  to  140.  Simultaneously  with  its  primary  acceleration,  the 
pulse  grows  small,  feeble,  and  soft.  After  a  while  radial  pulsation  is  re- 
placed by  a  mere  flickering  undulation.  At  length  even  this  ceases,  al- 
though death  still  lingers  for  minutes  or  hours,  and  even  the  possibility  of 
recovery  remains. 

In  pronounced  collapse,  pulsation  is  no  longer  felt  in  the  larger  vessels 
such  as  the  carotids,  brachials,  and  femoral s.  At  times,  however,  the 
pulse  though  exceedingly  feeble  may  be  felt  to  the  very  end.  And  this  may 
occur  even  in  cases  running  a  rapid  course.  On  the  other  hand  in  a  certain 
proportion  of  ^\foudi'ojiant"  cases,  it  disappears  early,  never  to  return. 

A  remarkable  fact  in  this  connection  deserves  mention  here,  namely 
that  i^eripheral  pulsation  may  be  quite  imperceptible  while  the  heart  still 
throbs  so  violently  as  to  cause  the  patient  to  complain  of  precordial  j^ain 
and  oppression. 

The  thickening  of  the  blood  and  arterial  spasm  (Johnson)  may  explain 
this  phenomenon.  Besnier  °  and  Lorrain  ^  have  found  that  sphygmographic 
tracings  taken  during  collapse  show  an  almost  horizontal  line  with  occa- 
sional faint  elevations  corresponding  to  the  diastole.  Lorrain  also  states 
that  dicrotism  when  present  is  more  marked  at  night  than  during  the 
day. 

In  slow  reaction  the  pulse  remains  small,  perhaps  filiform,  readily  com- 
pressible and  quite  frequent.  In  quick  reaction  it  is  much  less  compres- 
sible and  often  decidedly  bounding.  In  the  so-called  typhoid  reac- 
tion, the  pulse  may  be  ample,  but  it  remains  compressible,  and  often  shows 
marked  dicrotism.  It  has  little  stability,  and  slight  causes  produce  de- 
cided acceleration,  that  quickly  subsides  when  the  exciting  cause  ceases  to 
be  operative. 

Searle^  on  opening  arteries  during  the  attack  saw  the  blackish  blood 
exude  slowly.  iJieffenbach^  and  Magendin"  found  the  exposed  arteries  thin, 
narrow,  lax,  in  places  almost  collapsed.  When  cut  into,  some  vessels  were 
found  empty.  Once  in  the  case  of  a  moribund  patient,  Dieffenbach  intro- 
duced a  catheter  from  a  slit  in  the  axillary  artery  almost  into  the  heart. 

•  London  Lancet,  March  28,  1885. 

^  Besnier,  Recherches  sui;  la  nosographie  et  le  traitment  du  cholera.  These  de 
Paris,  1867.  =*  Etudes  de  medecine  clinique,  etc.     Paris,  1868. 

•*  Cholera:  Its  Nature,  Cause  and  Treatment,  etc.     London,  1866. 

*  Observations  physiologiques  et  chirurgicales  faites  sur  les  choleriques.  Ber- 
lin, 1835. 

•*  Legons  sur  le  cholera  morbus,  etc.     Paris,  1833. 


236  ASL\TIC  CHOLERA. 

But  no  blood  flowed  from  the  instrument,  nor  after  withdrawal  was  any 
found  in  its  interior.  Little  clots  have  also  been  seen  in  the  arterial  lumen, 
while  life  was  not  yd  extinct.  In  sharp  contrast  with  this  arterial  empti- 
ness we  find  venous  sbignation  occurring  during  the  progress  of  the  attack. 
The  never-absent  lividity  or  cyanosis  is  m  part  explained  in  this  way.  Ex- 
treme c3'anosis  is  favored  by  the  darkness  of  the  blood  and  previous  plethora. 
In  anemic  cholorotic,  or  cachectic  persons  this  bluish  or  purplish  hue  is 
replaced  by  a  more  leaden  lividity. 

In  consequence  of  venous  stagnation,  as  above  mentioned,  the  external 
veins,  especially  those  near  the  heart,  sometimes  rise  considerably  above 
the  level  of  the  skin.  The  vis  a  tergo  may  be  so  reduced  that  no  blood, 
or  only  ver}'  little,  issues  from  an  opened  vein,  although  the  vessel  may  be 
found  fully  distended  with  it. 

Owing  to  the  rapid  serous  depletion  the  previous  plumpness  of  the  body 
quickly  disiippears.  The  tissues,  in  place  of  being  bathed  in  healthy  serous 
fluid,  are  called  upon  to  give  up  their  own  juices.  Emaciation  is  therefore 
speedily  developed,  and  may  progress  to  an  extreme  degree;  as  Marey  has 
tersely  expressed  it,  choleraics  even  during  life-time  become  cadavers 
{ies  clioleriques  Ze  cadaver isent). 

According  to  Graef e, '  except  during  the  agony  of  death,  retinal  circu- 
lation continues;  but  in  no  other  pathological  condition  is  the  volume  of 
retinal  blood  found  so  much  reduced.^ 

The  profound  blood-stagnation  witnessed  in  cholera  is  brought  about 
by  a  combination  of  causes.  It  is  in  large  measure  due  to  the  great  thick- 
ening and  increasing  viscidity  of  the  fluid.  Griesinger  has  pointed  out 
that  the  reduced  temperature,  especially  pronounced  in  the  distal  parts  of 
the  body,  is  also  a  factor  to  be  taken  into  account  in  this  connection. 

Another  potent  cause  of  this  stasis  is  the  great  reduction  of  cardiac 
power.  And  there  can  be  no  doubt  that  in  many  cases  death  in  the  period 
of  collapse  is  the  immediate  consequence  of  heart-failure.  The  nutrition 
of  the  central  organ  of  circulation  must  quickh'  suffer  along  with  that  of 
the  body  at  large.  An  added  cause  of  cardiac  weakness  may  be  found  in 
disturbed  innervation,  so  often  seen  where  sudden  abdominal  disease-pro- 
cesses are  lit  up,  and  besides  all  these  causes  the  specific  action  of  ptomaines 
or  other  poisons  belonging  to  cholera  doubtless  greatly  influences  the  en- 
tire vaso-motor  apparatus.  It  is  in  this  way  that  we  may  admit  the  factor 
of  vascular  spasm  so  strongly  insisted  upon  by  Johnson  and  his  followers. 

The  blood  is  necessarily  changed  both  quantitatively  and  in  its  compo- 
sition, by  the  enormous  intestinal  hydrorrhagia.  A  primary  alteration 
due  to  specific  infection  has  been  often  assumed  but  never  positively  dem- 
onstrated. 

As  regards  the  diminution  in  volume,  it  is  of  course  proportionate  to 
the  amount  of  transudation.  In  some  very  severe  cases  Monneret'  was  un- 
able to  collect  from  the  body   more  than  eight  or  ten  ounces. 

The  specific  gravity  of  choleraic  blood-serum  has  been  estimated  vari- 
ously as  103G  (Herrmann),  104:4  ("Wittstock),  and  1057  (Thomson). 
Healthy  blood-serum,  according  to  Garrod,  has  a  specific  gravtiy  of  1028, 

Various  microscopical  alterations  have  been  from  time  to  time  described 
as  occurring  in  the  corpuscles.  But  it  does  not  seem  that  observers  have 
been  able  to  discover  any  constant  and  characteristic  cliange.     "We  will, 

'  Archiv  fiir  Ophthalmologie,  vol.  xii. 

''  Compendium  de  medecine  pratique.     By  Monneret  and  Delaberge,  Paris. 


THE  RESPIRATORY  APPARATUS.  237 

therefore,  not  examine  the  theoretical  statements  advanced  by  different 
writers  to  account  for  such  changes,  as  they  claim  to  have  found. ' 

We  may  mention  here,  however,  that  an  increase  in  the  proportion  of 
leucocytes  to  colored  corpuscles  is  tolerably  certain;  but  its  pathological 
significance  is  in  every  event  a  mediocre  one. 

The  thickening  of  the  blood,  as  already  indicated  by  the  figures  show- 
ing increased  specific  gravity,  is  further  shown  by  the  tarry  or  s\Tuppy 
condition  of  the  fluid  as  it  flows  from  the  living  body,  or  as  it  is  found  in 
the  cadaver.  Coagulation  is  imperfect,  and  no  serum,  or  only  veiy  little, 
IS  separated  from  the  clot.  Sliaken  up  in  contact  with  air,  the  dark  color 
is  transformed  into  a  reddish  tint.  Schmidt  found  that  the  maximum 
tliickness  of  the  blood  was  readied  about  3G  hours  after  the  first  marked 
symptoms  of  an  attack.  During  the  period  of  reaction  the  blood  quickly 
imbibes  the  previously  lost  water— a  circumstance  that  may  possibly  ac- 
count for  the  persistence  of  thirst. 

The  large  proportion  of  urea  present  in  choleraic  blood  also  deserves  to 
be  mentioned.  It  Avas  noticed  by  O'Shaugnessy  ^  as  early  as  1S32.  Mar- 
chand,^  Scharlau,  Garrod,*  Schmidt,  Heller  and  others  confirmed  it  by 
subsequent  examinations.  O'Shaugnessy  found  as  much  as  one  grain  of 
urea  in  an  ounce  of  blood,  which  is  much  more  than  ordinarily  occurs  in 
Bright's  disease.  The  enormous  loss  of  water  of  course  results  also  in  an 
increased  proportion  of  the  other  solid  constituents  of  the  blood.  Thus 
we  find  more  salt,  more  phosphates,  and  more  potassium  compounds  than 
normal. 

The  Respiratory  Apparatus. — The  term  cholera  asphyxia,  as  Asi- 
atic cholera  has  been  frequently  called,  sufficiently  indicates  that  circulatory 
and  respiratory  disturbances  may  come  so  prominently  to  the  front  as  to 
push  other  symptoms  relatively  into  the  background. 

In  the  milder  forms  belonging  to  the  asphyxial  type,  if  type  it  deserves  to 
be  called,  there  is  seen  the  phenomenon  know  as  "air-hunger,"  associated 
with  which  there  is  a  sense  of  heavy  023pression.  In  more  violent  cases 
there  is  intense  respiratory  agony,  with  interrupted,  exaggerated,  acceler- 
ated breathing.  All  the  remaining  force  of  the  patient  seems  thrown  into 
the  one  great  effort  to  catch  his  breath.  But  extreme  cholera  dyspnoea  of 
this  kincl  is  only  rarely  seen.  On  the  other  hand,  it  not  infrequently  hap- 
pens that  a  patient  passes  through  an  entire  attack  of  cholera  Avithout 
visil)le  changes  in  the  mechanism  of  his  respiration.  From  beginning 
to  end  breathing  remains  natural.  And  even  in  fatal  cases,  patients  may 
be  for  hours  in  pulseless  collapse  without  any  apparent  interference  Avith 
normal  respiration. 

In  most  instances,  however,  the  thickening  of  the  blood  quickly  fol- 
lowing upon  the  copious  serous  transudation,  marks  the  beginning  of  al- 
tered breathing,  wliich,  as  just  stated,  may  result  in  violent  dyspnoea.  The 
fact  that,  even  in  such  extreme  cases,  auscultation  reveals  no  local  change 
adequate  to  explain  the  dyspnoea,  taken  in  conjunction  with  the  further 

'  The  most  recent  investigations  concerning  the  blood  alterations  of  cholera 
will  be  found  under  Morbid  Anatomy. 

'^  Repoi't  on  the  Chemical  Puthologj'  of  the  Malignant  Cholera;  containing 
analyses  of  the  blood,  dejections,  etc.     London,  1832. 

■*  Ueber  das  Vorkommen  des  Harntoffs,  etc.,  in  Erdmann's  Journal  fin-  prak- 
tische  Chemie,  vol.  xi.,  p.  458,  1887. 

■*  On  the  Pathological  Condition  of  the  Blood  in  Cholera.  London  Journal  of 
Medicine,  18^9. 


238 


ASIATIC  CHOLERA. 


circumstance  that  post-mortem  examinations  give  negative  pulmonary  evi- 
dence,, naturally  makes  us  look  elsewhere  than  in  the  lungs  for  an  expla- 
nation of  cholera-dyspnoea.  And  indeed  it  is  not  a  strained  assump- 
tion which  makes  the  altered  condition  of  the  hlood  and  the  weak- 
ened heart  responsible  for  the  difficult  breathing.  The  blood  is  thick  and 
viscid,  it  stagnates  in  the  veins  and  capillaries,  and  although  there  is  not 
enough  of  it  to  lead  to  oedema  or  marked  congestion,  yet  the  lieart  is  un- 
able to  propel  it.  Oxidation  is  necessarily  imperfect.  Cyanosis  of  the 
surface  thus  indicates  Avhat  may  be  termed  pulmonary  cyanosis.  In 
other  words  there  is  a  decided  preponderance  of  venous  over  arterial  blood. 

We  conclude,  therefore,  that  the  dyspnoea  of  cholera  is  preeminently 
a  cardiac  and  hsamatic  one,  and  that  pulmonary  disturbances  play  a  second- 
ary role  in  its  production. 

Attempts  have  been  made  to  measure  the  diminution  of  respiration  by 
an  examination  of  the  expired  air.  Although  scientific  accuracy  can  hardly 
be  claimed  for  these  investigations,  the  conclusion  is  nevertheless  war- 
ranted that  a  noticeable  diminution  of  carbonic  acid  exists  in  the  expired 
air  of  cholera  patients. 

Clauny  and  Baruel  even  went  so  far  as  to  assert  that  in  the  graver  cases 
the  air  was  returned  from  the  lungs  unchanged.  Davy  found  a  reduction 
of  two-thirds  in  the  amount  of  carbonic  acid  exhaled.  Eayer  also  dis- 
covered a  marked  lessening  in  the  amount  of  oxygen  absorbed.     (Laveran). 

Doyere'  made  as  many  as  70  analyses  of  air,  and  found  the  reduction 
proportionate  to  the  gravity  of  the  case.  He  concluded  from  his  exami- 
nations that  the  quantity  of  oxygen  consumed  and  carbonic  acid  produced 
became  progressively  less  until  the  end.  And  further,  that  a  return  to 
more  normal  respiratory  conditions  marked  the  advent  of  reaction.    ^ 

The  asphyxia  of  cholera  differs,  therefore,  from  ordinary  suffocation 
in  that  the  pulmonary  condition  is  one  of  ana?mia  rather  than  congestion, 
and  further  in"  the  fact  that  in  cholera,  cardiac  disturbances  precede  for  a 
long  period  the  pulmonary  disorder. 

Again  the  dyspnoea  of  cholera  at  times  becomes  a  veritable  orthopncea. 
Drasche  believes  that  a  tonic  spasm  of  the  diaphragm  may  account  for  this 
symptom,  which  is  generally  associated  with  ])recordial  pain  and  great  anx- 
ietv  on  the  part  of  the  patient.  The  respiratory  rhythm  may  be  changed 
in  such  a  manner  that  one  deep  inspiration  is  followed  by  a  number  of  short 
expiratory  efforts. 

It  has  been  already  pointed  out  that  the  expired  breath  of  cholera 
patients  often  feels  quite  cool.  The  number  of  respirations  varies  within 
wide  limits.  There  may  be  only  eight  per  minute;  and  again  the  num- 
ber may  exceed  -45. 

Romberg  has  called  special  attention  to  the  marked  diminution  of  sensi- 
bilitv  on  the  part  of  the  respiratory  mucous  membrane.  Accumulated 
secretions,  or  irritant  vapors,  excite  no  reflex  cough.  The  tracheal  rattle 
is  not  heard  in  death  from  cholera. 

At  the  height  of  the  attack,  visible  respiratory  movements  of  the  chest 
may  be  absent.  Auscultation  still  elicits  a  faint  inspiratory  murmur,  but 
expiration  is  noiseless. 

Drasche  frequently  heard  pleural  friction  sounds,  but  other  observers 
say  little  or  nothing,  about  their  occurrence. 

In  the  period  of  reaction,  bronchitis  and  various  pulmonary  inflamma- 

'  Comptes  Rendus,  1849,  and  Memoire  sur  la  Resph-ation,  etc.,  Paris,  1863. 


THE   TEMPERATURE. 


239 


tioiis  are  observed,  in  some  epidemics  forming  the  rule,  in  otliers  consti- 
tuting onl}'  exceptions. 

A  frequent  but  by  no  means  constant  respiratory  disturbance,  known 
as  the  vox  dialer ica,  consists  in  a  marked  alteratioii  of  the  voice.  At  first 
there  may  be  only  slight  hoarseness.  This  is  followed  by  more  decided 
huskiness,  then  comes  a  mere  whispering  voice,  and  finally  complete  apho- 
nia. The  change  in  the  patient's  voice  is  not  necessarily  in  correspondence 
with  his  general  condition.  Drasche  states  that  he  found  patients  at  the 
acme  of  a  rapidly  develoj^ed  attack  able  to  talk  plainly.  On  the  other 
hand  the  first  appearance  of  loose  bowels  may  be  immediately  followed  by 
a  changed  voice.  Indeed  in  some  ^\fQudroyant"  cases  complete  aphonia 
appears  simultaneously  with  the  initial  discharges.  Yet  there  can  be  no 
doubt  tliat  the  voice  may  improve  without  any  amelioration  of  the  patient's 
general  condition. 

Dr^Tiess  of  the  larjmx  and  vocal  chords,  or  an  atonic  condition  of  the 
laryngeal  muscles  have  generally  been  invoked  to  explain  this  singular 
phenomenon.  It  has  been  pointed  out  by  Drasche,  however,  that  dis- 
turbed innervation  is  apt  to  be  the  chief  factor  in  the  production  of  the 
vox  cholerica,  and  in  the  light  of  modern  research  this  is  the  proper  ex- 
planation of  the  peculiar  phenomenon  in  question. 

The  Temperature. — iVs  soon  as  the  transudation  of  fluid  into  the 
intestines  leads  to  disturbed  circulation,  the  peripheral  parts  of  the  body 
begin  to  grow  cooler.  From  the  hands,  the  feet,  the  ears  and  nose,  the 
coolness  gradually  extends  over  other  parts  of  the  body,  until  at  length 
the  entire  surface  may  have  an  almost  icy  feel.  In  marked  contrast  with 
this  objective  coldness,  which  has  been  often  borrowed  to  designate  one 
period  of  the  attack  as  the  algid  stage,  we  find  the  subjective  sensation 
of  heat  that  so  many  patients  complain  of. 

It  is  a  noteworthy  fact,  however,  that  although  the  thermometer 
indicates  a  decided  falling  off  in  the  bodily  heat,  nevertheless  this  is  by  no 
means  commensurate  with  the  sensation  of  coldness  communicated  to'  the 
palpating  hand  of  a  healthy  person.  Griesinger  accounts  for  this  apparent 
discrepancy  on  the  ground  of  a  reduction  in  the  loss  of  surface  heat  by 
irradiation  from  the  skin,  as  evidenced  by  the  slow  rise  of  the  thermometer. 
And  he  further  believes  that  the  clammy  feel  of  the  moist  skin  conveys  an 
exaggerated  idea  of  actual  coldness. 

This  certainly  is  a  very  plausible  view  of  the  matter,  and  may  be  ac- 
cepted as  sufiiciently  explanatory  of  the  phenomenon.  The  slow  rise  of 
the  thermometer  may  also  explain  the  difference  in  the  figures  given  by 
several  authors.  It  is  important,  therefore,  wdienever  accuracy  is  desired 
to  allow  the  instrument  to  remain  in  position  at  least  twenty  minutes. 

The  rapid  vacillation  of  the  temperature  of  the  body  is"  a  peculiarity 
belonging  in  a  greater  degree  to  cholera  than  to  most  other  diseases.  Thus 
it  may  happen  that  a  difference  of  seA^eral  degrees,  up  and  down,  occurs 
Avithin  an  hour.  Warmth  is  likewise  very  unevenly  distributed  throughout 
the  body,  one  part  being  quite  cold,  whereas  another  still  feels  decidedly 
warm. 

Whenever  the  coldness  of  the  body  is  at  all  pronounced  and  uniformly 
distributed,  its  degree  affords  a  sign  of  the  gravity  of  the  case.  Indeed, 
in  very  mild  attacks  the  body-heat  may  remain  normal  throughout. 

The  observations  of  Casper,  Czermak,  Magendie,  Burgieres,  Monneret, 
even  Briquet  and  Mignot,  v.  Biirensprung  and  other  earlier  writers  are 
untrustworthy  as  regards  registrations  of  the  bodily  temperature. 


240  ASIATIC  CHOLERA. 

But  the  later  repoi'tsof  Zimmermtiun,  Cliiircot,Guterbock,  Lorain,  have 
furnished  us  with  more  reliable  tigures.  From  these  it  appears  that  the 
temperature  varies  considerably  according  to  the  part  of  the  body  in  which 
it  is  taken.  The  dilference  between  axillary  and  rectal  warmth  may  be 
ten  or  twelve  degrees  in  the  collapse  stage. 

Leubuscher  gives  the  following  table,  showing  comparative  average 
temperatures: 

Axilla 92.7°  F. 

Under  the  tongue  .  .  .  .  .  .90.5° 

Upon  the  tongue    .  .  .  .  .  .  .81.5° 

In  the  nose    ........       79.2° 

On  the  palm  of  the  hand 84.0° 

The  temperature  of  the  mouth  is  generally  too  low  to  be  utilized  as  an 
index  of  tlie  general  heat  of  the  body.  The  same  applies  to  the  nostrils 
and  tongue.  There  can  be  no  doubt  that  evaporation  of  moisture  from 
these  parts  brings  about  some  lowering  of  temperature.  It  has  been 
maintained  by  a  few  writers  that  the  coldness  of  the  expired  air  was  an 
additional  factor  at  work  in  this  direction.     But  this  is  quite  im})robable. 

During  reaction  normal  or  slightly  elevated  temperatures  are  observed. 
Rapid  falling  off  in  the  tempei'ature  at  this  period  is  a  grave  prognostic 
sign;  and  rapid  elevation  of  temperature,  except  when  reaction  begins, 
is  also  an  unfavorable  symptom. 

In  the  typhoid  state  a  regular  rhythm  is  not  discoverable,  the  tempera- 
ture being  still  subject  to  sudden  fluctuations,  from  causes  that  escape  de- 
tection. Just  as  we  find  a  post-mortem  elevation  of  several  degrees,  so 
there  may  occur  a  decided  ante-mortem  rise.  The  latter  is  found,  how- 
ever, only  within  the  body.  From  accurate  records  of  74  patients-,  Lo- 
rain' tabulates  the  following  figures: 

Deep  rectal  temperature. 
Minimum.  Maximum. 

93.2°  F.  in  1  case.  104.0°  F.  iu  5  cases 

95.         "      2  cases.  102.2      "     15     " 

96.8       "    10     "  100.4      "    27     " 
98.6      "    28     "  98.6      "      2     " 

100.4      "    11     " 

The  axilla,  but  more  especially  the  extremities,  show  miTch  greater  oscil- 
lations. Magendie  reports  cases  where  the  hands  and  feet  showed  a  tem- 
perature of  only  G4.5°-70°  F.     Lorain  records  the  following: 

Temperatures  in  the  moutli. — 77°  F.,  1  case;  80.6^,  1  case;  82.4°, 
2  cases;  84.2°  4  cases;  8G°,  G  cases;  87.8°  5  cases;  89.6°,  7  cases;  91.4°, 
5  cases;  93.2°,  G  cases;  95.0°,  4  cases;  96.8°,  6  cases;  98.6°,  3  cases. 

In  healthy  reaction  blood  and  warmth  return  simultaneously  to  the 
peripheral  parts,  and  the  previous  internal  elevation  sinks  back  to  the 
normal  standard. 

If  reaction  is  interfered  with,  owing  to  the  presence  of  complications, 
the  blood  may  return  to  the  distal  parts,  while  their  temperature  still 
remains  lower  than  it  should  be.  But  this  does  not  militate  against  the 
assertion  that  diminished  peripheral  circulation  is  largely  responsible  for 
the  low  temperatures  of  distal  parts  in  the  period  of  attack. 

The  Integument. — The  changes  occurring  in  the  color  of  the  skin 
constitute  a  prominent  symptom  of  cholera.     The  distal  parts  are  first  seen 

'  Etudes  de  niedecine  elinique,  Paris,  1868. 


THE  INTEGUMENT.  241 

to  lose  their  natural  hue,  and  invariably  the  discoloration  is  more  marked 
there  than  over  the  trunk.  Pallor  generally  precedes  the  lividity  and  ex- 
treme cyanosis  of  an  advancing  attack.  The  reduction  in  temperature 
just  described  is  accompanied  ^m/v'  jkcssu  with  deepening  cyanosis.  In 
the  absence  of  the  latter  the  parts,  as  a  rule,  are  observed  to  retain  their 
warmth. 

Between  the  frequency  and  copiousness  of  the  discharges  and  tlie  cuta- 
neous discoloration  a  similar  correspondence  does  not  appear  to  exist.  For 
in  some  cases  a  few  large  discharges  will  find  the  patient  cyanotic  to  the 
last  degree,  whereas  in  others,  repeated  evacuations  are  followed  by  only 
slowly  increasing  blueness. 

In  rapidly  developed  deep  cyanosis,  intense  oppression,  dysj^noea,  abo- 
lition of  reflexes,  and  a  semi-comatose  condition  are  not  infrequently  seen. 
Indeed  it  was  for  a  long  time  customary  to  speak  of  a  paralytic,  asphyctic, 
or  cyanotic  stage. 

Beginning  cyanosis  is  first  seen  about  the  eyes,  the  finger-nails  and 
toes.  In  thin  patients  the  turgescenee  of  superficial  vessels  often  becomes 
well-marked.  Hemorrhagic  extravasations  into  the  skin,  but  more  par- 
ticularly into  the  conjunctiva,  have  been  observed  as  a  consequence  of  this 
repletion. 

On  account  of  unequally  distributed  lividity  or  cyanosis  the  skin  often 
assumes  a  marbled  appearance.  Drasche  frequently  saw  cutis  anserina 
j^rincipally  over  the  chest,  abdomen  and  arms.  A  great  variety  of  hues 
may  be  seen  in  different  cases,  owing  to  the  differences  in  healthy  com- 
plexions. Cyanosis  is  not  always  present  in  cholera.  In  fact  Levy  has 
described  a  separate  class  of  cases  under  the  heading  of  white  cholera, 
on  account  of  the  persistent  absence  of  this  symptom. 

Cholera  cyanosis  differs  essentially  from  the  similar  discoloration  of 
other  diseases  in  being  associated  with  more  or  less  marked  cutaneous 
changes  that  have  no  resemblance  to  ordinary  conditions;  whereas  the  skin 
in  the  usual  diseases  accompanied  by  cyanosis  is  if  anything  thickened, 
swelled,  or  oedematous,  the  very  opposite  is  seen  in  cholera.  For  in  this 
disease  the  integument  quickly  shrinks  and  shrivels,  losing  its  turgescenee 
and  elasticity.  It  becomes  wrinkled  at  the  finger-tips  and  in  other  distal 
13arts,  A  fold  pinched  up  does  not  readily  subside.  The  eyelid  may  be 
pulled  in  any  direction  without  resuming  its  natural  position,  except  very 
slowly,  A  parchment-like  cutaneous  hardness  may  develop.  But  often, 
instead  of  being  quite  dry  and  hard,  the  breaking  out  of  a  clammy  sweat 
leads  to  persistent  moistness,  Nevertheless  perspiration  is  rarely  observed 
all  over  the  body.  The  forehead,  neck,  and  hands  may  be  found  bedewed 
with  viscid  sweat,  that  collects  in  large  drops,  while  the  trunk  has  a  dry, 
leathery  feel.  Cold  sweat  is  always  a  graver  symptom  than  warm  perspi- 
ration, but  a  favorable  prognosis  is  not  justified  merely  on  the  strength  of 
a  change  from  one  to  the  other. 

It  has  been  noticed  that  jmtients  would  sink  into  collapse  after  the 
appearance  of  copious  sweating,  as  if  the  withdrawal  of  even  this  small 
amount  of  fluid  had  produced  a  deleterious  effect.  More  probably,  how- 
ever, deejDer  causes  are  here  at  work,  and  the  sweat,  though  seemingly  a 
primary,  is  in  fact  a  secondary  manifestation. 

The  touch  of  a  moist  choleraic  skin  may  very  aptly  be  compared  to 
that  of  amphibious  animals. 

Cholera  sweat  has  an  alkaline  reaction  in  collapse.  Later  on  it  again 
becomes  sour. 

IG 


242 


ASIATIC  CHOLERA. 


Cutaneous  sensibility  may  suffer  to  such  an  extent  that  sinapisms, 
blisters  and  other  irritants  produce  no  visible  effect. 

Drasche  states  that  when  blistering  does  occur  the  patient  experiences 
no  pain  therefrom.  Cauterization  singes  but  does  not,  according  to  Gries- 
inger,  lead  to  blistering  of  the  skin. 

When  cut  into,  the  skin  looks  bloodless,  the  severed  edges  do  not  gape, 
and  the  general  appearance  is  that  seen  in  the  cadaver. 

That  cutaneous  and  subcutaneous  absorption  is  rarely  completely 
abolished  has  been  shown  by  many  experimental  trials.  That  it  is  always 
more  or  less  impaired  is  equally  certain. 

The  loss  of  cutaneous  elasticity,  coupled  with  the  shrinking  and  atrophy 
of  the  underlying  soft  parts,  results  in  such  changes  of  facial  expression 
that  patients  are  scarcely  recognizable.  Perhaps  the  most  conspicuous 
alteration  is  witnessed  in  connection  with  the  eyes.  The  lids  are  not 
moved  over  the  entire  surface  of  the  bulb.  The  latter  falls  back  into  the 
bony  orbit,  and  even  the  cornea  may  become  somewhat  wrinkled  on  account 
of  loss  of  intraocular  fluid.  Often"^it  is  seen  to  be  dr}^  speckled  with  accu- 
mulating dust,  and  later  it  is  quite  opaque.  Seitz  has  seen  the  cornea 
undergo  rapid  softening,  becoming  converted  into  a  pappy  substance. 
Mummification  of  the  sclerotic,  especially  in  its  lower  segment,  is  often 
observable.  Extravasations  into  the  conjunctiva,  the  choroid  and  sclero- 
tic have  been  frequently  noticed. 

The  general  atrophy  and  rapid  emaciation  seen  ni  cholera  belongs  in 
like  degree  to  no  other  disease.  The  face  especially,  as  already  stated,  shows 
u  marked  wasting  that  results  in  an  expression  of  countenance  not  easily 
forgotten  when  once  seen.  The  chief  characteristics  of  this  fades  chol- 
erica  having  been  previously  described,  need  not  be  here  repeated. 

In  advanced  cases  the  extremities  appear  to  consist  solely  of  bone  and 
wrinkled  skin. 

When  pathological  accumulation  of  fluid  distends  the  skin  or  fills  the 
cavities  of  the  body,  a  speedy  absorption  is  inaugurated  with  the  onset  of 
cholera.  Barlow  has  narrated  the  case  of  a  man  suffering  from  dropsy,  who 
passed  large  quantities  of  watery  fluid,  and  though  he  became  livid  and 
clammy,  made  a  good  recovery.  But  "when  he  began  to  recover  from 
cholera  his  appearance  was  almost  ludicrous,  from  the  manner  in  which 
the  integment  hung  loosely  about  him. "'  Similar  instances  have  been  also 
described  by  other  writers. 

The  Urinary  Organs. — The  kidneys  secrete  only  sparingly  shortly 
after  the  first  onset  of  the  disease,  the  urine  having  a  high  degree  of  con- 
centration. Soon  only  a  few  drops  at  a  time  are  passed,  and  a  little  later 
entire  suppression  supervenes.  But  in  some  cases  the  last-named  symp- 
tom is  absent.  Patients  have  stated  that  urine  flowed  from  them  along 
with  the  rice-water  discharges,  and  their  statements  have  been  verified  by 
competent  observers. 

But  the  complete  suppression  of  urine  in  other  cases  is  equally  certain. 
Now  the  structural  alteration  of  the  kidneys  at  the  early  period  when  sup- 
pression first  occurs,  is  quite  inadequate  to  explain  this  remarkable  mani- 
festation. 

In  acute  and  chronic  nephritis  the  actual  histological  damage  is  much 
greater,  and  yet  some  urine  is  often  secreted  until  the  very  last.  But  in 
cholera  the  early  appearance  of  albumen  makes  it  quite  probable  that  cir- 
culatory disturbances  cause  the  symptom  in  question.  Eecent  renal  experi- 
mentation   has  clearlv  shown  that  diminished  arterial  tension  may  lead 


THE  URINARY  ORGANS.  243 

to  albuminiTria.  Yenous  stasis  may  have  and  does  have  a  like  effect. 
Both  factors  are  present  in  cholera,  and  it  is  reasonable  to  suppose  that 
albuminuria  and  suppression  of  urine  precede  the  more  deep-seated  patho- 
logical changes  that  choleraic  kidneys  undoubtedly  undergo. 

It  is  very  creditable  to  Griesinger,  and  L.  Meyer  to  have  pointed  out 
the  possibility  of  explaining  the  symptoms  under  discussion  in  this  me- 
chanical way,  long  before  positive  experimental  evidence  was  obtained  or 
obtainable,  ^ 

Cholera  patients  often  complain  of  a  desire  to  micturate  without  the 
ability  to  pass  water.  Under  those  circumstances  it  may  be  found  expedient 
to  introduce  a  catheter.  Generally,  however,  little  or  no  urine  will  flow 
from  it.  Nor  is  it  always  an  easy  matter  to  introduce  the  catheter,  on 
account  of  the  violent  urethral  spasm  provoked  by  attempts  to  pass  the 
instrument  into  the  bladder.  Anuria  may  persist  for  hours  and  days.  In 
some  cases  it  has  been  observed  to  last  over  a  Aveek.  The  reappearance  of 
urine  witnessed  in  reaction  may  once  more  give  way  to  suppression,  as 
the  patient  passes  into  a  typhoid  state. 

Anuria  should  not  be  confounded  wnth  absence  of  desire  for  micturi- 
tion.    The  catheter  will  decide  the  question  as  to  which  condition  prevails. 

In  13  cases  carefully  watched  by  Lorain,  urinary  secretion  was  resumed 
between  the  second  and  eighth  days  of  the  disease.  The  following  table 
indicates  the 

Amount  of  Urine  passed  and  the  Day  of  Resumiition. 

Amoi-nt  in  Litres 
Cases.                                       Day.                                        for  HA  hours. 

1 3 1.0 

2 6 1.6 

3 2 0.5 

4  3  8.0 

5 7 4.0 

6 2 0.8 

7 3 1.0 

8 8 2.6 

9 6 1.0 

10 3 3.0 

11 6 3.0 

12  4 0.7 

13 3 1.3 

The  urine  of  the  early  stage  of  an  attack  of  cholera  is  rich  in  salts,  it 
deposits  urates,  and,  as  already  said,  may  contain  albumen.  The  first 
urine,  after  suppression  has  existed  for  one  or  several  days,  has  a  muddy 
yellow  or  brown  color.  Its  specific  gravity  very  rarely  exceeds  1010,  and 
is  often  as  low  as  1006.  It  is  more  or  less  albuminous.  In  exceptional 
instances  albumen  may  be  missed.  Urea  and  sodium  chloride  are  found 
in  considerably  reduced  proportions.  Occasionall}'  the  latter  is  entirely 
wanting. 

In  addition  such  urine  may  deposit  crystals  of  iiric  acid,  casts,  various 
epithelia,  leucocytes,  red  ])lood-corpuscles,  and  oxalate  of  lime.  Sugar, 
bile-pigments,  hippuric  acid  and  indican  may  be  discovered,  but  only  in 
small  cpiantities.  Parkes  believes  that  vesical  and  renal  (?)  catarrhs  in- 
variably accompan}^  or  follow  an  attack  of  cholera. 

The  Alhiirninuria  of  ChoJera  has  been  studied  by  many  observers. 
Hermann,  Simon  and  other  earlier  writers  did  not  fail  to  mention  it. 

'  Compare  also  the  researches  of  Straus,  detailed  under  Morbid  Anatomy. 


244  ASLITIC  CHOLERA. 

In  1S49  its  importance  was  pointed  out  by  Levy,  Gcndrin,  Rostan,  and 
Martin-Solon.  In  Germany,  Heller,  von  Oettinger,  Oppolzer  and  Vogel 
drew  early  attention  to  it.  Since  then  it  has  occupied  the  attention  more 
particularly  of  Legroux,  Gubler,  Jaccoud,  Lorain,  Buhl,  Virchow,  Giiter- 
bock,  Lebert,  Drasche,  Klebs,  Thomson,  Parkes,  Griesinger  and  Laveran, 

The  milder  form  of  temporary  albuminuria,  chiefly  caused  by  disturb- 
ances of  circulation,  may  be  followed  by  more  permanent  and  graver  affec- 
tions, involving  structural  changes  of  the  kidne^^s.  Nevertheless  even  the 
latter  have  scarcely  ever  been  known  to  lead  to  chronic  Bright's  disease. 
Of  course  it  should  not  be  forgotten  that  the  very  cases  where  such  an 
event  might  have  occurred  belong  to  that  category  in  which  recovery  is 
an  exceptional  matter.  It  follows  from  what  has  here  been  described  that 
the  condition  of  the  urinary  organs  may  furnish  important  evidence  with 
regard  to  prognosis.  An  early  resumption  of  secretion,  with  progressive 
diminution  of  albumen  and  steady  increase  of  the  amount  of  urine  voided, 
is  a  very  favorable  sign. 

On  the  other  hand,  much  albumen  and  the  recurrence  of  complete  sup- 
pression are  to  be  regarded  as  ominous  symptoms. 

Gli/cosuria  has  been  repeatedly  observed,  but  it  seems  to  be  a  merely 
temporary  phenomenon  belonging  to  the  stage  of  reaction.  Parkes  found 
sugar  in  moderate  amounts  on  the  first  and  second  days  of  reaction. 
Gubler  '  claims  to  have  discovered  glycosuria  in  very  many  instances.  He 
also  believes  this  sign  to  be  quite  characteristic  of  those  cases  in  which 
cholera  is  more  slowly  developed  than  ordinarily.  On  the  whole,  however, 
the  inference  is  warranted  that  glycosuria  has  no  special  significance,  either 
as  a  prognostic  sign  or  otherwise. 

Polyuria,  which  generally  comes  on  after  or  about  the  fourth  day  of 
reaction,  has  a  physiological  rather  than  pathological  or  clinical  interest. 
Still  it  marks  the  reestablishment  of  absorptive,  assimilative  and  secretory 
power,  and  is  most  frequently  seen  in  cases  of  complete  and  rapid  reac- 
tion. 

That  the  polyuria  is  not  merely  the  result  of  drinking  much  water 
appears  from  the  fact  that  the  solids  are  excreted  in  larger  amount  than 
might  be  supposed.  Thus  Buhl  ascertained  that,  while  the  quantity  of 
urea  passed  with  the  concentrated  urine  of  the  first  24  hours  of  reaction 
rarely  rose  above  one  drachm,  the  amount  excreted  during  polyuria  might 
rise  above  two  ounces.  A  corresponding  augmentation  was  found  in  the 
amounts  of  the  other  solid  constitutents.  Giiterbock  and  Lorain  report 
similar  observations. 

The  General  Secretions. — Apart  from  the  urine,  the  other  excre- 
tions and  secretions  of  the  body  show  more  or  less  constant  changes  both 
as  regards  quantity  and  quality. 

The  secretion  of  cold,  viscid  sweat  has  already  been  mentioned.  Chemi- 
cal examination  has  elicited  the  fact  that  it  contains  urea. 

Doyere  and  Poirson  state  that  they  discovered  grape-sugar  in  the  per- 
spiration of  cholera  patients  during  the  period  of  attack.  Burguieres 
claims  that  the  reaction  is  alkaline  throughout  the  attack,  and  that  the 
acidity  is  only  restored  with  beginning  reaction. 

The  buccal  and  salivary  secretions  are  diminished  to  a  much  greater  ex- 
tent than  the  cutaneous  secretions.     The  tongue  and  mouth  may  become 

'  Sur  la  glycosuiie  sympt.  dans  la  periode  react,  du  cholera.  Gaz.  des  hopi- 
tanx,  186G. 


THE  NERVOUS  SYSTEM.  245 

quite  dry  in  consequence.     A  pappy  coating  is  sometimes   seen  on  the 
mucous  surfaces  of  the  oral  cavity. 

Frua  says  that  choleraic  saliva  contains  a  large  proportion  of  chloride 
of  ammonium.  And  he  is  inclined  to  regard  this  as  characteristic  of 
cholera.  At  times  it  may  have  a  sour  reaction;  as  a  rule  it  remains  alka- 
line. 

Bile  continues  to  be  found,  though  in  reduced  amount,  throughout  the 
■whole  attack. 

The  laclirymcd  secretion  suffers  considerably.  It  may  become  entirely 
suppressed.  The  changes  resulting  therefrom  to  the  cornea  and  conjunc- 
tiva have  already  been  described. 

A  coating  of  viscid  material  forming  a  thin  film  or  a  deeper  layer  of 
mucoid  appearance,  is  seen  in  some  instances. 

The  normal  exudation  moisture  upon  serous  membranes,  the  formation 
of  cerebro-spinal  fluid,  the  generation  of  parenchymatous  juices  are  all 
seriously  impaired. 

As  regards  the  formation  of  mUh  in  puejperal  women,  while  not  abol- 
ished it  is  quickly  reduced  to  a  minimum,  Drasche  found  the  milk  thick, 
of  marked  alkaline  reaction,  with  an  almost  complete  absence  of  chlorides 
and  casein,  and  a  dimiiiution  of  sugar,  albumen  and  other  ingredients. 

The  Organs  of  Generation, — Uterine  bleeding  and  utero-vaginal 
hemorrhages  are  often  seen  during  an  attack  of  cholera,  A  remarkable 
feature  of  their  occurrence  is  found  in  the  fact  that  they  may  arise  after 
the  menopause. 

If  a  menstruating  woman  is  attacked,  the  flow  may  be  abruptly  checked, 
I)ut  it  usually  reappears  with  the  advancing  disease.  The  hemorrhage  is 
sometimes  quite  profuse,  thus  adding  one  more  potent  factor  to  the  many 
causes  of  exhaustion  and  collapse  already  present.  In  the  later  stages  of 
cholera,  metritis  Avith  diphtheritic  ulceration  is  no  unusual  event,  and 
justifies  a  bad  prognosis.  The  ovaries  become  the  seat  of  hemorrhage 
(which  generally  takes  place  into  the  Grafian  follicles)  in  a  certain  pro- 
portion of  cases. 

Concerning  the  male  organs,  nothing  requiring  special  notice  is  known 
to  occur.     The  urethra  is  drA'and  maybe  the  seat  of  smarting  sensations. 

The  Nervous  System. — During  an  attack  of  cholera,  marked  symp- 
toms occur  in  connection  with  the  central  nervous  system.  But  it  is  note- 
worthy that  the  primary  impression  of  choleraic  infection  is  much  milder 
than  in  cases  of  enteric  fever.  The  remarkable  views  of  Chapman,  attrib- 
uting the  entire  disease  to  jDrimary  nervous  impressions,  are  noticed 
elsewhere. 

The  early  neurotic  manifestations  of  an  attack  of  cholera  are  of  a  purely 
functional  character.  It  is  quite  late  in  the  course  of  the  malady  that 
actual  structural  alterations  begin  to  appear.  In  fact  CA'en  in  the  typhoid 
stage,  meningitis  and  encephalitis  are  exceptional  occurrences. 

The  repletion  of  cranial  blood-vessels,  oedema,  the  accumulation  of  urea 
in  the  substance  of  the  brain,  and  similar  processes,  no  doubt  are  responsible 
in  some  degree  for  what  is  seen  during  the  life-time  of  the  patient.  Never- 
theless the  entire  sitbject  is  still  involved  in  uncertainty,  and  there  is 
room  for  more  accurate  investigation.  The  role  plaj'ed  by  ptomaines  and 
their  poisonous  effects  upon  the  nerve  centers  also  require  further  eluci- 
dation. 

In  the  beginning  of  an  attack  the  patient  frequently  complains  of 
general  malaise.     Tinnitus  aurium,  vertigo,  a  vague  sense  of  anxiety  may 


246  ASIATIC   CHOLERA. 

then  come  on,  especially  with  the  appearance  of  the  first  evacuations. 
Then  weakness,  a  changed  expression  of  countenance,  and  gi-eat  restless- 
ness follow. 

Intelligence  may  remain  clear,  but  there  is  marked  apathy  amounting 
to  utter  indifference  to  all  things  in  the  graver  cases.  In  the  milder  ones 
the  patients  may  indeed  seem  apathetic,  but  they  are  nevertheless  acutely 
attentive  to  their  own  condition  as  well  as  to  everything  that  is  going 
on  about  them. 

Slight  somnolence,  torpor,  some  confusion  of  ideas,  hardness  of  hearing, 
much  diminished  cutaneous  sensibilitj^,  amblyopia,  then  deejiening  somno- 
lence, followed  by  coma,  are  among  the  most  frequent  effects  of  cholera  upon 
the  nervous  system.  If  somnolency  makes  way  for  renewed  intelligent 
activity,  a  favorable  turn  in  all  other  respects  is  the  rule,  and  recovery 
is  soon  ushered  in. 

Cholera  patients  generally  complain  but  little.  Griesinger  remarks 
that  the  first  impression  a  cholera- Avard  makes  upon  the  visitor  is  one  of 
surprise  at  the  reigning  quietude. 

There  are  cases,  however,  and  they  always  belong  to  the  class  of  gi*aver 
ones,  where  patients  are  loud  in  their  complaints  and  lamentations.  They 
feel  dizzy,  are  oppressed,  there  is  pra?cordial  pain,  they  constantly  crave 
cold  drinks  and  suffer  from  internal  heat,  they  shift  their  position  in  bed 
to  the  best  of  their  reduced  ability,  they  cry  and  weep,  sometimes  scream- 
ing or  moaning  from  the  torture  of  incessant  cramps. 

In  ordinary  attacks  of  cholera,  active  delirium  is  not  seen.  Drunkards 
and  very  aged  persons  may  mumble  and  mutter  in  low  delirium.  In 
violent  reaction  and  in  the  tyjahoid  stage,  moderate  delirium,  or  stupor, 
headache  and  sleeplessness  are  more  or  less  common. 

As  a  general  rule  all  spinal  reflexes  are  abolished  in  cholera  collapse. 
Sprinkled  Avith  cold  water  such  patients  make  no  response;  tickling  of  the 
throat  is  not  followed  by  gagging  or  vomiting;  irritant  vapors  provoke  no 
cough.  The  sphincters  no  longer  act.  AVhat  urine  is  secreted  accu- 
mulates in  the  bladder,  injections  are  returned  from  the  bowels,  vomiting 
ceases,  the  voice  lias  died  awa}'. 

In  this  connection  there  may  be  mentioned  the  observations  of  Dr.  A. 
Josias,'  Avho  during  the  recent  outbreak  in  Paris  had  occasion  to  observe 
about  30  cases  of  typical  cholera.  From  a  clinical  study  of  these  cases  he 
concludes  that  the  tendon  reflexes  are  more  or  less  exaggerated  at  the  be- 
ginning and  during  the  activity  of  an  attack.  In  convalescence  and  after 
recovery,  on  the  other  hand,  they  are  normal  or  even  diminished.  In 
graver  cases  of  rapid  development  exaggerated  tendon  reflexes  appear  to 
occur  constantly.  "When  the  disease  is  developed  more  slowly  this  is  a 
frequent  but  not  constant  phenomenon.  In  mild  cases  the  reflexes  remain 
normal. 

The  occurrence  of  mnscular  cramps,  which  has  given  the  disease  the 
title  of  spasmodic  cholera,  remains  to  be  considered.  In  true  cholera 
more  or  less  violent  spasms  of  single  muscles  and  whole  groups  of  muscles 
are  rarely  absent.  It  is  singular  to  observe,  however,  how  variable  the 
extent  and  intensity  of  this  symptom  may  be  in  different  epidemics. 

The  character  of  the  contractions  is  always  that  of  tonic  spasm,  and 
the  pain  occasioned  thereby  differs  greatly  in  different  individuals. 

Speaking  broadly,  it  is  certain  that  robust  and  previously  healthy 
persons  suffer  more  "than  the  weakly  or  decrepit.       This  fact  was  already 

'  Du  reflexe  tendineux  dans  le  cholera.    Le  Progres  Medical,  December  31, 1884. 


THE  NERVOUS  SYSTEM. 


247 


noticed  in  India  many  years  ago,  where  Searle  found  the  stronger  Europeans 
much  more  frequently  attacked  by  spasms  than  the  more  or  less  degen- 
erate natives.  Searle's  observations  have  been  confirmed  by  Macnamara 
and  other  later  writers.  Macnamara  says  in  this  connection:  "Among 
the  weak  and  poverty-stricken  people  of  Lower  Bengal,  the  contractility 
of  their  muscular  fibers  is  at  so  low  a  standard  that  they  frequently  escape 
the  cramps  from  which  their  more  lusty  up-country  brethren,  or  Eu- 
ropeans, suffer  so  fearfully." 

Although  almost  all  the  muscles  of  the  body,  including  even  some  of 
the  involuntary  ones,  may  be  affected,  it  is  commonly  only  the  extremities 
that  develop  marked  cramps.  Moreover  the  flexors  appear  to  be  oftener 
attacked  than  the  extensors.  Usually  after  the  first  few  copious  evac- 
uations, and  when  the  pulse  is  beginning  to  fail,  these  cramps  make  their 
appearance.  The  calves  suffer  first;  then  the  fingers  and  toes  become 
bent  and  rigid;  next  the  chest,  neck  and  abdomen,  and  at  length  the  back 
is  implicated.  Visible  lumps  of  great  hardness  may  mark  the  position  of 
the  larger  superficial  muscles.  The  facial  muscles  and  those  of  the  jaw 
escape  in  the  vast  majority  of  cases.  Yet  Bouillaud  saw  a  dislocation  of 
the  inferior  maxilla  in  consequence  of  choleraic  spasm.  The  exciting 
cause  of  the  tonic  spasms  of  choleraics  is  obscure.  The  absence  of  other 
signs  of  spinal  disturbance,  the  negative  post-mortem  evidence,  and  the 
further  circumstance  that  the  symptom  is  not  a  constant  one,  militate 
against  the  view  Avhich  attributes  their  appearance  to  a  direct  toxic  irri- 
tation of  the  spinal  cord  by  the  cholera  poison.  Frey  and  others  assert 
that  the  spasms  originate  in  reflex  irritaton  starting  in  the  gastro-intestinal 
mucous  membrane.  This  explanation  receives  some  support  from  the 
well-known  fact  that  convulsions  may  be  due  to  such  causes,  especially  in 
children. 

It  has  also  been  claimed  that  the  imperfect  and  unhealthy  blood-supply 
of  the  nerve-centers  produces  these  contractions. 

Griesinger,  Potain  and  others  believe  that  local  muscular  anasmia  is 
accountable  for  the  distressing  phenomenon,  and  adduce  much  evidence 
in  support  of  this  view.  AVliat  little  blood  is  received  by  the  muscles  is 
physically  and  chemically  so  much  altered  as  to  furnish  irritation  rather 
than  nourishment  for  these  organs. 

In  summing  up  the  debatable  question  under  consideration,  Stille 
remarks  that  "  probably  all  of  these  factors  are  associated  causes  in  pro- 
ducing the  spasmodic  phenomena  of  cholera.  It  is  well  worthy  of  notice 
however,  that  spasms,  which  are  so  frequent  in  all  infantile  diseases,  and 
especially  in  those  affecting  the  stomach  and  bowels,  rarely  attack  chil- 
dren suffering  from  cholera.  This  Avould  seem  to  prove  that  the  spasms 
in  question  are  not  reflex,  but  either  central  and  spinal  or  else  muscular 
— an  inference  which  is  strengthened  by  their  being  tonic  and  not  clonic. " 

It  does  not  seem  probable  or  even  possible  that  all  these  causes  are 
operative  at  the  same  time  in  the  same  case.  An  inference  which  seems 
warranted  by  the  evidence  now  at  our  command  is  that  different  causes 
may  be  at  work  in  different  cases.  In  the  opinion  of  the  writer,  Griesin- 
ger's  explanation  is  a  more  j)lausible  one  than  any  of  the  others.  The 
altered  muscular  metabolism  is  clearly  shown  by  the  loss  of  water  de- 
scribed by  Middeldorpff,  the  increased  proportion  of  urea  pointed  out  by 
Buhl,  and  the  excess  in  creatine  noticed  by  Hoppe.  The  convulsions  at 
times  observed  in  the  typhoid  state  are  uremic,  and  not  characteristic 
of  cholera. 


248  ASIATIC  CHOLERA. 


CHAPTEH  XXIX. 

THE  COURSE,  DURATION  AND  MORTALITY  OF  CHOLERA. 

The  course  of  cliolera  lias  been  amiily  illustrated  in  the  foregoing,  so 
that  it  seems  scarcely  necessary  to  again  consider  it  here.  But  it  will 
be  interesting  and  instructive  to  examine  some  statistical  evidence,  more 
particularly  as  regards  the  mortality  of  the  disease.  This  will  further 
elucidate  the  course  and  duration  of  the  disease,  and  thus  justify  the  title 
placed  at  the  head  of  the  cliapter. 

As  has  been  previously  jjointed  out,  the  death-rate  from  cholera  is  a 
very  variable  one.  Xot  only  do  different  epidemics  show  variations  that 
are  found  equally  extreme  in  no  other  disease,  but  the  same  epidemic  has 
a  mortality-rate  that  is  constantly  changing.  One  fact,  however,  has  been 
universally  observed,  namely,  that  the  early  history  of  an  epidemic  is  asso- 
ciated with  the  largest  number  of  victims,  and  that  there  is  a  tendency  to 
gradual  mitigation  even  while  the  disease  ma}'  continue  to  spread.  The 
wide  territorial  extent  of  an  epidemic  is  not  necessarily  coupled  with  a  high 
degree  of  mortality.  If  anytliing,  the  death-rate  diminishes,  so  that  places 
reached  late  may  suffer  but  little,  as  if  the  virulence  of  the  infecting  agent 
had  become  exhausted  in  traveling  long  distances.  For  this  reason  we 
should  have  less  dread  of  the  disease  in  our  own  country  than  may  be 
reasonably  felt  abroad.  And  if  the  partially  exhausted  poison  reaching 
our  shores  is  not  called  back  to  renewed  life  and  malignant  potency  by 
finding  favorable  conditions  for  further  development  in  the  accumulated 
dirt  and  refuse  of  large  cities,  then  we  may  forever  hoj^e  to  escape  the 
horrors  and  panic  of  a  largely  fatal  epidemic.  The  recent  Parisian  out- 
break (188-4)  affords  a  good  illustration  of  the  peculiarity  just  mentioned. 

Cholera  after  ravaging  Southern  France,  Italy,  and  Spain,  at  length 
appeared  in  the  French  capital.  But  being  already  rather  exhausted  with 
its  long  travels,  and  meeting  with  little  encouragement  in  the  way  of  dirt, 
water-contamination  and  other  unhygienic  conditions,  it  Avas  quickly  sup- 
pressed. 

Some  early  epidemics  are  reported  to  have  killed  only  5  per  cent,  of 
those  attacked.  This  seems  highly  improbable.  On  the  other  hand,  sev- 
eral more  recent  outbreaks  are  positively  known  to  have  had  a  death-rate 
varying  between  70  and  90  per  cent.  A  broad  average  shows  a  mortality 
not  far  either  way  from  50  per  cent. 

The  death-rate  is  evidently  influenced  in  some  measure  by  the  geogi-aph- 
ical  situation  of  a  place,  increasing  as  we  approach  the  equator,  and 
diminishing  in  proportion  as  we  recede  from  it. 

Local  causes  have  a  marked  bearing  on  the  death-rate.  The  quality 
of  the  soil  on  which  houses  are  built,  the  drainage,  the  hygienic  conditions 


THE  MORTALITY  OF  CHOLERA. 


249 


surrounding  the  patients,  are  all  influential  in  causing  a  high  or  low 
mortality. 

There  appears  to  be  no  constant  difference  in  the  death  rate  of  general 
hospitals  as  compared  with  private  residences.  It  should  be  remembered 
that  the  "general  hospital"  cases  are  recruited  from  the  poorer  classes  of 
society,  and  further  that  on  admission  the  disease  has  already  made  more 
or  less  headway.  There  is  no  doubt  that,  general  hospitals  show  a  higher 
death-rate  than  cholera  hospitals.  When  the  disease  spreads  from  a 
cholera  ward  to  the  general  wards  a  high  mortality  is  inevitable.  Thus  in 
the  epidemic  of  1854  Haller  found  in  the  Vienna  General  Hospital  a  death- 
rate  from  cholera  of  52  per  cent,  in  the  cholera  wards,  whereas  the  mor- 
tality from  the  same  disease  in  the  general  Avards  rose  to  74  per  cent. ,  and 
the  same  experience  was  had  in  the  great  epidemic  of  the  following  year. 

Leubuscher  reports  a  death-rate  of  52.5  per  cent,  in  the  cholera  hos- 
pital of  Berlin,  at  a  time  (1850)  when  the  general  city  mortality  was  60 
per  cent.  A  well-managed  cholera  hospital  is,  therefore,  calculated  to 
save  lives  that  would  ordinarily  be  sacrificed. 

We  have  just  seen  that  the  average  run  of  hospital  cases  is  apt  to  be 
more  severe  than  in  private  practice.  But  there  are  compensating  circum- 
stances that  should  not  be  lost  sight  of.  It  is  evident  that  immediate  medical 
interference  may  in  some  cases  at  least,  avert  the  impending  fatal  issue. 
Now  even  with  the  most  intelligent  assistance  of  trained  nurses,  the 
general  practitioner  is  clearly  placed  at  a  disadvantage,  when  compared 
with  his  hospital  confrere,  who  is  ever  ready  to  obey  on  the  instant,  the 
urgent  summons  of  his  patients. 

In  studying  the  records  of  mortality  statistics,  the  fact  must  not  be  lost 
sight  of  that  they  will  vary  in  accordance  with  the  prevalent  medical 
belief  of  a  country.  If  during  an  epidemic  the  majority  of  physicians 
report  all  cases  of  diarrha3a  as  belonging  to  the  category  of  Asiatic  cholera, 
there  will  naturally  be  very  many  recoveries,  and  a  corresponding  decrease 
in  the  death-rate  results  therefrom.  If,  on  the  other  hand,  only  the  fully 
pronounced  cases  are  allowed  to  be  cholera,  the  opposite  will  take  place; 
i.e.,  there  will  seem  to  be  a  very  high  death-rate. 

Drasche  has  made  the  practical  suggestion  that  the  appearance  of  rice- 
water  dejections  be  taken  as  an  index  of  the  presence  of  true  cholera. 
While  this  may  not  be  pathologically  correct,  it  Avill  nevertheless  insure 
uniformity  of  reports,  and  thus  enable  us  to  prepare  trustworthy  statistics. 

The  valuable  monograph  of  the  above  writer  contains  a  series  of  in- 
structive tables  that  afford  a  better  illustration  of  the  various  factors 
influencing  mortality  than  lengthy  descriptions  can  hope  to  convey.  Sev- 
eral of  these  tables  are  here  reproduced: 


Mortality  at  Mannheim  in  1849.     (Frey). 

General. 

Males. 

Females. 

Age. 

^Per  cent.-^ 

^Per  cent.— ^ 

^Per 

cent.-^ 

Recovered.         Died. 

Recovered.         Died. 

Recoverefl. 

Died. 

1  to  10  years. . . . 

43.1 

56.9 

51.8 

48.2 

36.4 

63.6 

10  "  20     "      ... 

58. 

42. 

59. 

41. 

56.3 

43.7 

20  "  30     "     .... 

67.5 

32.5 

60. 

40. 

70.9 

29.1 

30  "  40     "     

54.6 

45.4 

51. 

49. 

.57.7 

42.3 

40  "  50     "      .... 

48. 

52. 

6.3 

4.3.7 

39.6 

60.4 

50  "  60     "      .... 

36. 5 

63.5 

36.  :J 

64.7 

37.5 

62.5 

60  "  70     "      .... 

43.2 

56.8 

40. 

60. 

45.2 

54.8 

70  years  and  ovei- 

34.5 

75.5 

35. 

65. 

26. 

84. 

250 


ASIATIC  CHOLERA. 


Mortality  at  Copenhagen  in  1853  (Hiibertz). 

0-3 71.3  per  cent. 

3-15 52.1    "      " 

15-30 45.4    "      " 

30-50 63.1    "      " 

50-60 76.2    '<      " 

Over  60 86.0    "      " 

It  is  unnecessary  to  make  any  comment  upon  the  significance  of  these 
figures. 

If  we  turn  now  to  London  and  examine  the  official  returns  of  the 
epidemic  of  1854,  we  will  have  to  read  the  same  lesson: 

Mortality  at  London  in  1854.    (Official  Returns.) 

15-35 34.9  per  cent. 

25-35 35.4  ^'  " 

85-45 43.4  "  " 

45-55 50.1  "  " 

55-65 58.3  "  " 

65-75 71.4  "  " 

75-85 78.3  "  " 

The  following  table  will  be  found  instructive,  being  based  on  1,630 
personal  observations  with  careful  records  made  by  Drasche  in  Vienna  in 
the  years  of  1854  and  1855: 


Mortality  at  the  Vienna  General  Hospital 

in  1854  and  1855. 

5IALES. 

Females. 

Age. 

Died. 

Re- 
cov'd. 

&     . 

1 1 

Died. 

Re- 
cord. 

0;  O  rf 

<0       to 

M     a; 

&   'e: 

Pi     « 

1-10      

18 
67 
81 
61 
48 
66 
43 

9 

145 

109 

63 

43 

18 

5 

69 
33 
43 
50 
53 
79 
89 

31 
68 
57 
50 
47 
21 
11 

10 
56 
153 
90 
50 
64 
28 

4 
64 
175 
66 
33 
12 

3 

71 
47 
47 
58 
■  60 
84 
90 

29 

11-30   

53 

31-30     

53 

31-40 

42 

41-50 

40 

51-60 

16 

61-89 

10 

The  following  tables  Avill  be  found  of  still  greater  interest,  as  presenting 
an  accurate  statement  of  the  mortality  from  cholera  and  various  factors 
influencing  the  same,  in  the  United  States,  during  the  epidemic  of  1873. 
They  are  taken  from  Dr.  McClellan's  report. ' 

It  is  clearly  seen  from  a  study  of  these  tables,  and,  indeed,  of  all  re- 
liable mortality  statistics,  that  the  death-rate  advances  quite  steadily  with 
the  increasing  age  of  the  patients.  In  Drasche's  Vienna  Hospital  table, 
an  apparently  excessive  mortality  is  recorded  for  the  ages  from  one  to 
twelve  years.  This  is  due  to  the  fact  that  the  death-rate  of  very  young 
children  is  an  extremely  high  one,  and  having  been  included  in  his  com- 
putation has  resulted  in  an  average  that  is  seemingly  above  the  usual  one. 


'  Washington,  1875;  pj).  34,  35. 


MORTALITY  STATISTICS. 
Statistics  of  Ages,  United  States  Epidemic  of  1873. 


251 


Age. 

3 

< 

S 
< 

S 
0 

■I 

0 

'Sb 

u 

0 

3 

a 
1-1 

1 

1 

"S 
a 

c 

s 

'3 
0 

i 
.1 

i 

0 

X 

V 

s 

1 

i 

"i. 
f 

.    1 

A      0) 
0     Ph 

6 

i 

i 

.5 

> 

1 

t 

C3 

Under  1  mo. 
One  month. . 
Two  months. 
Three  month 
Four  months 
One  year.  . . . 
Two  years. .. 
Three  "      ... 
Four     "     ... 
Five      "     .  . 
.5-10    "     ... 
10-20    "     ... 
20-30    "     ... 
30-40    "     ... 
40-50    "     ... 
.50-60     "     ... 
60-70     "     .   . 
70-80     "     ... 
80-90    "     ... 
113  years. . . . 
Unknown  .  . . 

i 

3 
3 

"i 

3 

25 
33 
38 
19 
4 
2 

i 
'5 

"4 

12 

18 

9 

2 

18 

28 

45 

74 

37 

22 

6 

5 

1 

7 

'2 

1 
2 

'3 

"i 

1 

2 

43 

i 
1 

"4 

6 

3 

6 

6 

26 

40 

57 

70 

30 

21 

14 

6 

1 

151 

'2 

4 

3 

4 

5 

4 

21 

39 

71 

68 

44 

24 

16 

6 

1 

li 

"i 
2 

7 
8 
8 
1 

"4 

2 
2 
1 
2 

21 

29 

20 

17 

13 

48 

231 

373 

355 

265 

165 

101 

37 

6 

1 

34 

'2 

1 

16 

16 

9 

8 

9 

11 

23 

108 

68 

54 

43 

14 

1 

33 

i 
'i 

4 
12 
16 
22 
10 
6 
1 

i 
i 

2 

2 

1 

i 

i 

'5 

11 

14 

11 

11 

41 

81 

147 

154 

100 

63 

34 

9 

8 

63 

*i  '. 
1 . 

18. 

28  . 

21  . 
7. 

10. 

42  . 

56  . 
143 
164 
105 

62. 

38. 
6  . 

46! 

'.         "\ 
'.        '1 

8 
.      33 

.      68 
.      44 
.      39 
.      34 
.      94 
212 
i    541 
3   480 
2    364 
.    112 
.      66 
.      10 
4 

'.    315 

6  2321 

i 

15 

7 
7 
3 

1 

34 

"2 
"3 

4 

8 

5 
6 
9 
6 
5 
3 

35 

2 
3 
8 
5 

7 

105 

174 

133 

103 

93 

310 

756 

1565 

1533 

956 

533 

299 

84 

18 

1 

686 

Total 

137 

283 

55 

2 

441 

323 

32 

1712 

405 

73 

7 

746 

740 

7356 

These  different  tables  fairly  represent  the  average  mortality,  and  the 
death  rate  as  influenced  more  particularly  by  the  age  of  patients.  With 
regard  to  infantile  mortality  they  are  not  accurate.  A  large  experience  of 
many  epidemics  has  shown  that  up  to  and  below  one  year  of  age,  the 
death-rate  is  frightfully  high — generally  above  92  per  cent.,  and  often 
reaching  98  per  cent. 

In  old  age  the  death-rate  is  likewise  very  high,  but  less  excessively 
so  than  in  early  infancy. 

As  a  matter  of  course  weak,  debauched  and  cachectic  individuals  of 
middle  life  contribute  a  far  larger  proportion  of  deaths  than  the  strong 
and  robust. 

Griesinger  calculates  that  in  large  cities  about  half  the  number  of  deaths 
are  observed  in  those  at  the  time  or  recently  sick  and  ailing.  On  the  other 
hand,  Dr.  Gairdner  mentions  that  the  post-mortem  examinations  of  chol- 
eraics  in  Edinburgh  showed  very  little  disease  in  the  bodies  of  those  who 
died  there. 

The  lower  classes,  for  easily  understood  reasons,  show  a  higher  rate  of 
mortality  than  the  well-to-do  and  wealthy. 

Occupation  plays  a  role  in  the  production  of  mortality  only  in  so  far 
as  debilitating  work  or  unhealthful  surroundings  may  vitiate  constitutional 
vigor.  Thus  Goodeve  found  in  India  that  the  privates  and  non-commission- 
ed officers  of  regiments  suffered  more  than  the  officers.  He  says  further 
that  fatigue,  want,  grief,  fright,  have  douljtless  some  degree  of  influence, 
though  it  would  be  difficl^lt  to  estimate  how  much.  Of  these  he  considers 
fatigue  the  most  injurious. 


252 


ASIATIC  CHOLEEA. 


A  study  of  the  general  mortality  of  cholera  is  made  additionally  inter- 
esting b.y  keeping  in  view  the  death-rate  of  the  various  periods  of  the 
disease.  It  is  singular  how  scanty  are  reliable  statistical  records  elucidating 
these  jDoints. 

Statistics  of  Sex,  Social  Condition  and  Results  of  the  United  States  Epidemic 

of  1873. 


Male 

Female 

White 

Black  

Married  .... 

Sinj^le 

Widowed. .  . 
Condition  in 
life  unkn'wn 

I  [.|  J  Male  .. 

I I  >  ( Female 
I ; 5. i Male  .. 
a[a'(  Female 

.[^(Male  .. 
"  ^1  Female 
2  ( Male  . . 
^  [il Female 
_,  ^  I  Cases  . . . 
il  Recov's. 
1 1  •  Deaths. . 

I  i  Unk'wn 

Tot.  Recov's 

Total  Deaths 

Tot.  Results 

Unknown. 


Grand  Total. 


88168 
49115 
69151 
68132 
55129 
80153 
2  1 


22  54 
12  28 


137 


102  9 
18146 


283  55 


203 

171 

353 

21 

212 

148 

14 


112 

91 

2 

5 

81 

69 


11 
266 
164 

11 


441 


179 

144 

312 

11 

183 
108 

27 

5 
39 

27 


1 
132 

114 
8 
2 


6713 
256 '19 


323  32 


954 
750 
1351 
653 
979 
672 
53 


342 
246 
137 
124 
264 
199 
211 
181 


849 

855 


252 
153 
217 
188 
203 
174 


22 
33 
3 

19 
9 
93 
54 
107 
53 


98 
307 


1712   405 


73 


420 
267 
624 

63 
314 
311 

40 

22 

99 

24 

13 

5 

279 

222 

"29 

16 

59 

4 

55 


145 
601 


746 


373 
356 
687 

42 
354 
293 

39 

43 

171 

187 

12 

5 

180 

149 

10 

15 

11 


11 
375 
354 

11 


740 


1179 
875 

1229 

825 

930 

930 

66 

128 


332 
221 
173 
237 
172 
233 
198 
267 
255 
12 


1469 
852 


2321 


34 


23  3950 

122951 

33  4854 

2'2047 

28|3456 

6  2955 

1    259 


11 


231 

1411 

1003 

445 

351 

1393 

1047 

701 

550 

455 

316 

109 

30 

3526 

3800 

30 

7356 


A  table  based  on  805  cases  under  the  personal  observation  of  Drasche 
was  published  by  him  in  1866,  and  is  here  reproduced: 

Death-rate  at  Different  Periods  of  an  Attack. 


Age. 

CM 

o 
o 

m 

o  . 

m 

•A 

a 
6C.2 
.S-- 

If 
■So 

.3  o 

Death-rate 

of 

Cholera-Tj-phoid 

Died. 

Recov'd. 

to  10  years  

Percent. 

32 
165 

248 

147 

78 

76 

59 

Percei't. 

34.3 

22.4 

29. 

36 

48.7 

55.2 

66.1 

Per  cent. 

25. 

50.3 

44.7 

37.4 

28.2 

9.2 

5. 

Per  cent. 

34.3 
15.1 
16.5 
15.6 
14.1 
28.9 
28.8 

Per  cent. 

6.2 
12.1 

9.6 
10.8 

8.9 

6.5 

0. 

Percent. 

&4.6 
55.5 
63. 
58.9 
61.1 
81.4 
100. 

Per  cent. 

15.3 

11 
*>1 

"  20       "     

"30      "     

44.5 
37. 

31 

"40      "     

41.1 

41 

"50      "     

38.8    ' 

51 

"60      "     

18.6 

61 

"88      "     

0. 

THE  MORTALITY  OF  CHOLERA. 


253 


From  an  examination  of  this  table  it  appears  that  death  occurred  in 
36.2  per  cent,  of  all  cases  during  the  period  of  active  discharges;  death 
took  place  in  the  typhoid  condition  in  18.6  per  cent,  of  the  cases.  Re- 
coveries after  reaction  amounted  to  35.9  Y>er  cent,  and  after  the  develop- 
ment of  typhoid  symptoms  to  only  9. 1  per  cent. 

The  high  mortality  of  cholera-typhoid  is  likewise  apparent  from  the 
figures  of  Pfenfer,  who  places  the  death-rate  at  59  per  cent. ;  Leubuscher 
Avho  records  67  per  cent.,  and  of  Liibstorff  who  saw  71  per  cent.  die. 

The  time  of  death  is  well  shown  by  examining  the  mortality  of  the 
first  Parisian  epidemic.  4,907  fatal  cases  were  reported.  Of  this  number 
there  died  after  the  disease  became  established: 


204  cases  in  from  1  to  6  houre. 


615  "     "   6  ' 

'  12 

392  "     "  12  ' 

'  18 

1173  "     "  18  • 

'  24 

823  on  the  2d  day. 

503  "  '^  3d   " 

382  "  "  4th  " 

240  "  "  5th  " 

125  on  the  6th  day. 
79  "     "    7th  •" 
171  "     "    8th    " 

35  "     "    9th    " 

36  "     "  10th    " 

111  between  10  and  14  days. 
19  in  the  third  week. 


According  to  English  reports  the  average  duration  of  an  attack  may 
be  i3ut  down  as  6  days.  In  fatal  cases  the  average  was  found  to  be  (London 
1854)  2. 68.  In  cases  ending  in  recovery  the  average  duration  of  the  disease 
was  ascertained  to  be  9.06  days.  This  illustrates  a  common  prognostic  ex- 
perience, namely  that  the  longer  the  fatal  issue  can  be  held  in  abeyance, 
the  better  are  the  patient's  chances  of  ultimate  recovery. 


254  ASIATIC  CHOLERA. 


CHAPTER   XXX. 

THE  COMPLICATIONS  AND  SEQUELS  OF  CHOLERA. 

An  attack  of  cholera  occurring  in  a  previously  healthy  person  is  ordi- 
narily so  quickly  decided  that  there  is  little  time  for  the  development  of 
complications.  In  the  stage  of  reaction,  however,  the  march  of  events  is 
comparatively  slow,  although  we  have  already  seen  that  in  scarcely  any 
other  disease  do  we  find  such  marvelous  changes  from  an  apparently  hope- 
less condition  to  one  of  safety  and  relative  well-being.  On  the  other  hand 
the  profound  circulatory  disturbances  of  cholera  may  eventuate  in  numer- 
ous local  congestions  and  inflammations,  that  cannot  be  discussed  seria- 
tim. E'or  this  reason  only  those  conditions  will  receive  attention  that 
are  known  to  be  of  more  common  occurrence,  whereas  the  rarer  forms  of 
sequeli»  will  be  merely  mentioned  in  passing.  The  condition  of  the  patient 
at  the  time  of  the  attack  must  necessarily  influence  to  some  extent  the 
course  of  the  disease.  It  is  especially  during  or  at  the  beginning  of  con- 
valescence that  a  number  of  disturbances  are  apt  to  arise  which  require 
to  be  separately  considered. 

In  the  flrst  place  we  may  speak  of 

Relapses. — There  can  be  no  doubt  that  reaction  may  have  been  fairly 
established  when,  from  some  cause  generally  escaping  detection,  a  return 
of  vomiting,  purging,  with  cyanosis  and  collapse,  takes  place.  This  is  by 
no  means  a  common  event,  but  when  it  happens  death  from  coma  is  a 
rule  that  admits  of  scarcely  any  exceptions.  Temporary  derangement  of 
the  digestive  organs,  following  some  slight  error  in  diet,  does  not  come 
under  the  head  of  actual  relapse  of  the  disease  itself,  although  it  may 
sometimes  simulate  such  a  condition. 

Exanthemata. — During  the  attack  proper  cutaneous  eruptions  are 
scarcely  ever  seen.  But  in  the  period  of  reaction  and  especially  as  conva- 
lescence seems  to  gain  the  upper  hand,  they  are  of  frequent  occurrence.  In 
some  epidemics  they  appear  in  almost  every  case;  in  others  they  are  of tener 
missed  than  seen.  These  eruptions  comprise  about  all  the  known  varieties 
of  acute  exanthemata.  Accordingly  we  find  erythema,  roseola,  urticaria 
the  various  vesicular  and  papular  eruptions.  Even  pustules  resembling 
variola,  and  erysipelatous  inflammations  may  be  developed.  At  times 
the  cholera  rash  may  closely  resemble  that  of  measles,  or  scarlatina,  while 
at  others  there  appears  a  marked  tendency  to  the  development  of  furun- 
culosis  and  deep  ulcerations.  Sometimes  only  a  few  scattered  boils  make 
their  appearance. 

The  appearance  of  the  various  simple  eruptions  is  not  heralded  by 
morbid  manifestations  of  any  kind.     A  catarrhal  hypergemia  of  the  con- 


COMPLICATIONS  AND  SEQUELS.  255 

junctiva,  throat,  or  tonsils  is  in  no  way  peculiar  to,  and  does  not  regu- 
larly precede  the  cutaneous  symptoms. 

It  is  in  the  second  week  of  the  disease,  several  days  after  the  urine  has 
again  begun  to  flow,  that  these  exanthemata  are  most  frequently  observed. 

A  more  or  less  pronounced  general  redness  of  the  skin  often  precedes  the 
distinctly  localized  eruptions.  Occasionally  this  diffuse  redness  is  accom- 
panied by  considerable  swelling,  in  which  case  the  patient  may  appear  to 
be  suffering  from  erysipelas.  But  in  a  few  hours,  or  after  a  day  or  two, 
the  redness  and  swelling  vanish,  leaving  only  larger  or  smaller  islands  of 
a  bright  red  appearance  scattered  over-  various  parts  of  the  body. 

In  other  cases  the  sequence  of  events  is  a  different  one.  Small  red 
spots  first  appear  on  the  hands  or  feet.  They  may  grow  in  size,  and  then 
other  patches  break  out  upon  the  neck  and  trunk. 

Even  when  the  exanthema  is  indistinguishable  from  urticaria,  itching, 
hurning  and  other  disagreeable  sensations  are  rarely  mentioned  by  the 
patients.  Desquamation  occurs  as  in  the  eruptions  of  acute  exanthematous 
diseases. 

The  maculae  fade  away  after  two  or  five  days,  and  branny  scales  are 
shed.  In  a  week  the  skin  has  regained  its  normal  appearance.  AVhen 
papules  or  vesicles  have  existed,  crusts  may  form  after  six  or  eight  days. 
These,  of  course,  are  more  slowly  shed.  Or,  what  is  rare,  the  skin  may 
peel  away  in  large  shreds,  after  an  efflorescence  resembling  scarlatina. 

Sometimes  the  skin  shows  scattered  pigmentations  for  a  longer  period 
as  an  index  of  former  eruptions. 

Of  course  the  occurrence  of  boils  essentially  modifies  the  usual  march 
of  events.  But  it  is  not  necessary  to  dwell  on  this  complication,  which  is 
in  no  way  peculiar  to  cholera.  The  post-mortem  examination  of  bodies 
that  showed  various  efflorescences  at  the  time  of  death  demonstrates  the 
fact  that  the  usual  reddish  eruption  of  cholera  is  due  merely  to  hypera?mia 
of  the  superficial  vessels,  with  moderate  serous  exudation.  Much  more 
serious  lesions  of  course  characterize  the  ulcerative  processes. 

The  variable  frequency  with  which  the  cholera-exanthem  appears  in 
different  epidemics,  is  Avell  shown  by  a  table  prepared  by  Drasche,  giving 
the  results  of  numerous  observations  by  careful  men. 

Frequency  of  the  Cholera  Exanthem. — According  to 

Haller  it  occurred  in 1.  per  cent  of  all  cases. 

Winge "        "        " 1.5  "  "  '*  «<  <« 

Horbye          "        " 20  "  "  "  "  " 

Harten"        «<        <« 2.3  "  *'  "  "  ♦' 

Muller  "        '^         " 2.5  "  "  "  "  " 

Lebert            <<        << 31  i^  <<  a  a  a 

Von.  Honigsberg    " 3.3  "  "  "  "  " 

ReinhartandLeubuscher         .        .        .        .    66.  "  "  "  "  " 

Joseph            "        <<  ....          11.5  "  "  "  "  " 

Meyer             <<        '<  ....          46.3  "  "  "  "  " 

As  regards  the  clinical  significance  of  the  appearance  of  a  cutaneous 
eruption,  the  opinions  of  various  authors  differ  to  such  an  extent  that  it 
is  impossible  from  the  evidence  before  us  to  decide  its  exact  meaning. 
Nevertheless  most  of  the  later  writers  agree  in  regarding  if  as  a  favorable 
prognostic  sign. 

Indeed,  Griesinger  is  inclined  to  attribute  consideral)le  importance  to 
it.  For,  in  his  experience,  death  is  rarely  seen  after  a  well-marked  cholera 
efflorescence.  And  a  decided  improvement  of  the  patient's  general  con- 
dition is  often  noticed  simultaneously  with  the  breaking  out  of  red  sjDots 
over  his  body. 


256 


ASIATIC  CHOLERA. 


Profuse  Perspiration. — Attention  has  already  been  called  to  the 
localized  breaking  ont  of  cold  clammy  sweat  dnring  the  period  of  attack. 
In  reaction  and  convalescence  profuse  perspiration  is  quite  frequent.  It 
is  more  uniformly  distributed  over  the  body  than  before,  and  may  work 
beneficially  by  carrying  oif  considerable  quantities  of  urea.  Acting  as  a 
vicarious  function,  it  may  relieve  the  kidneys  and  should  be  encouraged. 
It  is  noticeable  too  that  the  sweat  may  be  warm  and  grateful  to  the  pa- 
tient. Many  times  it  has  been  found  quite  odorous.  The  abundant 
presence  of  urea  in  this  perspii'ation  may  become  manifest  by  a  Avell- 
marked  deposition  of  fine  whitish  scales  upon  the  surface  of  the  integu- 
ment. 

Diphtheritic  and  other  Inflammations. — Inflammation  leading  to 
the  formation  of  false  membranes,  superficial  necrosis,  or  even  deep  ulcer- 
ation is  a  not  uncommon  complication  or  sequel  of  an  attack  of  cholera. 

Various  parts  of  the  body  may  Ijecome  the  seat  of  morbid  changes 
belonging  to  the  class  of  diphtheritic  inflammations. 

The  upper  air-passages  suffer  most  in  point  of  severity  and  frequency. 
But  the  bronchi,  the  stomach  and  bowels,  the  bladder  and  female  gener- 
ative organs  may  all  be  attacked. 

Even  npon  the  skin  diphtheritic  exudation  has  been  observed.  It  is 
unnecessary  to  give  a  detailed  account  of  the  symptomatology  of  these  affec- 
tions as  modified  by  the  previous  attack  of  cholera  which  the  patient  has 
suffered. 

Suffice  it  to  say  that  it  not  infrequently  happens  that  life  is  destroyed 
by  the  severity  and  extent  of  the  diphtheritic  inflammation. 

Croupous  inflammations  are  much  less  frequent  than  those  of  a  diph- 
theritic kind.  Croupous  pneumonia  may  sometimes  occur,  but  generally 
the  pulmonary  inflammations  are  catarrhal  and  hypostatic.  Peritonitis 
lias  been  observed,  but  it  is  quite  rare.  The  symptoms  of  these  secondary 
processes  are  naturally  not  as  characteristic  and  clearly  defined  as  when 
tlie  same  lesions  occur  as  primary  diseases.  And  as  the  kidneys  are,  as  a 
rule,  more  or  less  damaged,  various  degrees  of  ur^emic  disturbance  may 
be  superadded  to  further  obscure  the  localized  diagnosis  of  sequela?  of 
this  class.  There  is  rarely  a  sudden  invasion  of  new  disease.  The  rule 
is  that  all  these  secondary  processes  arise  in  an  insidious  manner.  They 
are  for  this  reason  not  infrequently  overlooked. 

Ocular  Troubles. — Conjunctival  injection  has  already  been  considered 
as  a  symptom  of  the  period  of  attack.  During  the  later  stages  of  the  dis- 
ease it  may  persist  as  a  troublesome  complication  or  even  lead  to  more 
serious  inflammatory  processes. 

Ulceration  of  the  cornea  is  often  observed.  It  may  be  limited  to  one 
eye,  but  in  numerous  instances  both  eyes  are  affected.  The  ulcers  may 
be  small,  superficial  and  multiple,  or  deeper  single  ulcers  arise,  that  may 
lead  to  perforation. 

Dr.  Goodeve  says  that  corneal  disintegration  occurs  most  frequently 
among  the  natives  of  India,  but  it  may  be  seen  in  Europeans  also.  An 
asthenic  state  of  the  system  is  necessary  to  its  production.  The  lower  seg- 
ment generally  suffers  first,  which  is  probably  due  to  the  fact  that  during 
complete  collapse  the  lower  lid  falls  away  from  the  uj^per  one,  causing 
desiccation  of  the  exposed  cornea.  This  segment  then  first  becomes  hazy; 
in  a  day  or  so  the  surface  epithelium  is  shed,  leaving  an  abrasion.  Then 
there  occurs,  loss  of  substance  in  the  deeper  layers,  resulting  in  a  distinctly 
visible  groove.     The  other  eye  may  now,  if  not  already  affected,  undergo 


COMPLICATIONS  AND  SEQUELS.  957 

the  same  changes.  "In  twenty-four  hours  more  the  groove  in  the  first 
eye  may  have  doubled  its  size.  Examined  with  a  lens,  the  surface  of  the 
groove  is  of  a  dirty  ash  color,  and  opaque,  having  indeed  all  the  character 
of  a  minute  slough.  The  ulcer  may  spread  and  penetrate  the  entire  thick- 
ness of  the  cornea,  and  extend  at  its  margins,  but  in  the  majority  of  cases 
the  patient  dies  before  such  extensive  destruction  occurs.*' 

When  the  patient  recovers,  the  eyes  rarely  show  permanent  serious  dis- 
figurement, in  spite  of  the  threatening  aspect  of  affairs  during  the  progress 
of  reaction.  According  to  the  author  cited:  "  There  is  first  arrest  of  dis- 
integration, then  diminution  of  haziness  and  opacity,  then  cleaning  of  the 
surface  of  the  ulcer,  which  becomes  beautifully  clear  and  transparent. 
Cicatrization  follows,  perhaps  rapidly,  and  the  repair  is  generallv  perfect, 
so  that  unless  the  ulcer  is  very  deep,  in  a  few  days  it  is'often  difficult  to 
discover  where  the  mischief  has  been.  Perjnanent  opacity,  hernia  of  the 
iris,  or  staphyloma  are  rarer  than  Avould  be  supposed.'' 

Aural  Affections,  in  the  shape  of  catarrhs  of  the  external  and  middle 
ear  are  rare.  But  deafness  or  hardness  of  hearing,  generally  quite  tem- 
porary in  nature,  has  been  described  by  numerous  authors. 

Unilateral  or  double  parotitis,  that  may  lead  to  extensive  suppuration, 
is  occasionally  observed.  Kayer  saw  parotitis  four  times  in  200  cases, 
Miiller  three  times  in  275,  but  Drasche  only  five  times  in  805  cases.  The 
symptoms  are  like  those  of  ordinary  mumps,  except  when  pus  is  formed. 
In  that  case  pyaemia  has  been  observed  to  develop,  with  a  fatal  result  in 
almost  every  instance. 

Paresis  and  paralysis  follow  an  attack  of  cholera  less  often  than 
they  do  attacks  of  other  infectious  diseases.  But  that  they  may  occur  can- 
not be  doubted. 

Gangrene  of  various  parts  occurs  ae  a  sequel  in  a  certain  proportion 
of  cases.  When  considerable  in  extent,  it  may  of  course  lead  to  death. 
Ordinarily,  however,  the  mortified  parts  are  only  small,  and  reparative 
processes  cause  an  early  separation  of  dead  from  living  tissue.  Goodeve 
has  seen,  among  the  natives  of  Bengal,  complete  gangrene  of  the  penis 
and  scrotum  that  invariably  terminated  in  death. 

Bed-sores,  ulcers  and  other  destructive  lesions  naturally  constitute  fre- 
quent sequelae,  that  may  cause  great  suffering,  and  considerably  retard  or 
even  jeopardize  the  establishment  of  complete  convalescence.  But  thev 
are  in  no  sense  peculiar  to  cholera,  and  require  merely  to  be  incidentally 
noticed. 

Prolonged  Gastro-intestinal  Derangements. — An  irritable  or 
extremely  sensitive  state  of  the  alimentary  canal  is  often  a  most  per- 
sistent sequel  even  of  a  comparatively  mild  attack  of  cholera.  When  we 
remember  that  the  specific  infecting  agent  appears  to  primarily  concen- 
trate its  baneful  force  upon  the  gastro-intestinal  mucous  membrane,  this 
peculiarity  should  not  surprise  us. 

Slight  errors  in  diet  often  result  in  serious  derangement  of  the  stomach 
and  bowels,  long  after  the  jmtient  has  successfully  overcome  the  acute  dis- 
turbance of  the  attack  itself. 

In  some  patients  moderate  diarrhoea  and  occasional  vomiting  persist 
for  days  and  even  weeks,  and  the  slightest  provocation  will  again  call  forth 
profuse  and  weakening  discharges. 

Some  patients,  on  the  other  hand,  show  a  tendency  to  constipation, 
which  it  may  be  dangerous  to  actively  interfere  with,  except  by  enemata. 
17 


258  ASIATIC  CHOLERA. 

Still  others  are  afflicted  with  the  various  forms  and  degrees  of  dyspepsia, 
that  may  remain  for  months  or  even  become  quite  chronic. 

Gastralgia,  enteralgia,  occasional  nausea  that  may  or  may  not  lead  to 
vomiting,  capricious  appetite  or  anorexia,  with  an  actual  impairment  of 
digestive  and  assimilative  power,  may  at  length  lead  to  a  pronounced  ma- 
rasmus and  debility.  It  has  happened  that  patients  gradually  failed  from 
this  inability  to  appropriate  sufficient  nourishment.  And  occasionally 
post-mortem  examinations  have  even  revealed  actual  gastritis. 

Careful  nursing,  however,  generally  finds  its  reward  in  a  gradual  res- 
toration of  digestive  power,  which  seems  to  show  that  many  of  the  symp- 
toms above  enumerated  depend  upon  functional  rather  than  structural 
changes,  and  that  actual  gastritis  is  a  rare  exception  rather  than  a  common 
occurrence,  as  has  been  supposed  to  be  the  case  by  some  writers. 


THE  CHOLERA  TYPHOID.  259 


CHAPTER  XXXI. 

THE    CHOLERA    TYPHOID. 

The  condition  generally  known  by  this  name  is  one  of  the  most 
common  forms  of  retarded  recovery,  and  may  well  be  separately  con- 
sidered. It  has  received  its  designation  from  a  group  of  more  or  less 
prominent  symptoms  that  in  some  respects  resemble  those  of  an  attack  of 
t^'phoid  fever. 

Before  or  near  the  end  of  the  first  week  the  patients,  instead  of  show- 
ing the  ordinary  signs  of  normal  reaction,  begin  to  complain  of  severe 
headache,  feeling  "as  if  the  head  were  in  a  vise.  "  There  is  vertigo  and 
great  psychical  depression  with  increasing  debility. 

In  many  cases  the  patients  lie  quietly  on  their  backs,  with  half -closed 
eyes  and  open  mouths.  Somnolence  is  often  marked,  and  on  being 
roused  they  answer  reluctantly  and  Avitli  hesitancy,  but  in  the  beginning 
still  intelligently.  Later  on  the  somnolence  deepens  to  soj^or  or  coma. 
Xo  response  to  questions  can  then  be  elicited.  Sometimes  amblyopia, 
diplopia,  mild  hallucinations,  tinnitus  and  other  cerebral  symptoms  pre- 
cede the  sopor.  Delirium,  agitation  and  jactatation.  the  refusal  of  nottr- 
ishment  and  medicines,  and  similar  signs  are  frequently  observed. 

In  rare  instances  muscular  spasms  again  arise.  Trismus  and  tetanoid 
or  even  epileptiform  con\Tilsions  have  also  been  noticed,  especially  in  chil- 
dren. 

The  brain  symptoms  are  associated  with  a  marked  febrile  movement, 
which  is  of  short  duration,  however.  The  eyes  are  bloodshot  and  a  creamy 
substance  gathers  over  the  cornea  and  collects  in  either  canthus.  If  the 
eyeball  became  •wrinkled  and  dry  in  the  stage  of  collapse,  it  may  now 
speedily  recover  its  tension  and  moisture.  There  is  noticeable  an  unnat- 
ural look  about  the  lustrous  ej'es  that  baffles  accurate  description.  The 
pupils  are  small,  and  decided  photophobia  may  develop.  The  pulse  may 
remain  normal,  but  generally  it  is  found  somewhat  accelerated.  Later 
on  it  becomes  slightly  retarded.  Pronounced  dicrotism  is  frequent.  At 
first  rather  full  and  bounding,  it  gradually  weakens  as  sopor  advances. 

Schmidt  states  that  during  the  cholera  typhoid,  the  blood  is  again  red 
and  fluid,  that  it  coagulates  readily,  Ijut  that  it  shows  a  large  proportion 
of  urea.  The  character  of  the  breathing  varies  considerably.  For  when 
the  typhoid  state  develops  respiration  seems  at  first  much  easier;  there  is 
absence  of  pr^ecordial  oppression  and  dyspnoea;  the  breath  grows  warm. 
But  later  on  the  respirations  become  deep,  slow  and  sighing;  they  lose 
their  rh}i:hm,  and  may  even  grow  quite  labored. 

These  changes  are  not  accounted  for  by   a  physical  examination  of 


260  ASIATIC  CHOLERA. 

the  chest,  which  generally  reveals  only  more  or  less  catarrh,  with  some 
hyi^ostatic  congestion.  The  latter  rarely  leads  to  true  pneumonia  involv- 
ing one  or  more  lobes.  But  disseminated  catarrhal  inflammations  of  small 
extent  are  not  infrequently  lit  up  in  both  lungs.  Hemorrhagic  infarc- 
tions also  cccur,  but  not  Avith  great  frequency. 

The  voice  may  grow  stronger  again  and  sound  clearer  in  the  early  period 
of  the  typhoid  state,  yet  it  does  not  fully  return  to  its  normal  condition, 
and  often  completely  fades  away  as  the  disease  progresses.  In  those  cases 
of  cholera-typhoid  which  are  largely  due  to  the  retention  of  urea  and  other 
by-products  of  tissue-metamorphosis,  we  find  a  cutaneous  deposition  of 
urea  over  many  parts  of  the  body.  Even  the  mucous  membranes  may 
show  a  thin  deposit  of  this  urinary  ingi-edient. 

The  various  cholera-exanthemata  previously  described  may  all  occur  in 
cholera-typhoid.  Gastro-intestinal  disturbances  are  always  present.  The 
tongue  may  be  moist  and  furred,  or  red  and  glossy,  and  later  it  generally 
becomes  dry  and  covered  with  dark  crusts.  It  trembles  on  being  ex- 
truded from  the  mouth.  There  is  no  appetite  and  occasional  vomiting  oc- 
curs; the  vomited  matters  are  bilious  and  contain  carbonate  of  ammonia. 
Hiccough  is  often  an  annoying  symptom  on  account  of  its  persistence.  Diar- 
rhoea is  quite  usiial.  The  stools  look  yellowish  or  green,  and  may  be  more 
or  less  distinctly  fecal.  Flakes  of  sanguiuolnnt  mucus  are  often  seen,  and 
sometimes  unmistakable  dysenteric  discharges  occur.  In  other  cases  the 
evacuations  are  fetid,  which  generally  indicates  diphtheritic  ulceration. 
Moderate  tympanitis  and  abdominal  tenderness,  together  with  a  somev>^hat 
enlarged  spleen,  are  other  common  signs  of  the  cholera  typhoid.  A  fetid 
discharge  from  the  vagina  may  show  that  diphtheritic  ulceration  exists  in 
the  female  organs  of  generation. 

There  can  be  no  doubt  that  some  of  the  symptoms  characterizing  the 
typhoid  state  are  directly  due  to  urtemic  intoxication.  But  the  view 
which  discards  all  other  influences  and  makes  the  typhoid  condition 
identical  with  urtemia  pure  and  simple  does  not  appear  tenable,  even  when 
upheld  by  the  authority  of  men  like  Frerichs.  Dietl,  Eeuss,  Griesinger 
and  others  have  distinctly  shoAvn  that  cholera-typhoid,  especially  in  its 
milder  forms,  may  be  a  simple  fever  of  reaction  or  irritation  {Reizfieber). 
The  attack  of  cholera  has  produced  a  gi-ave  impression  upon  the  entire 
system;  all  functional  activities  have  been  modified  or  suspended.  In  the 
final  revulsion  that  decides  the  contest  between  disease  and  constitution 
in  favor  of  the  latter,  the  remaining  energies  have  become  exhausted.  A 
condition  of  profound  prostration  ensues,  while  the  functions  gradually 
return  to  the  normal  standard. 

When  the  typhoid  condition  of  the  patient  is  really  the  direct  result 
of  urtemia,  as  happens  in  a  goodly  proportion  of  cases,  the  febrile  symp- 
toms are  insignificant  as  compared  with  the  other  grave  disturbances 
already  described.  In  such  cases  there  seems  to'  Ijc  a  flooding  of  the  sys- 
tem with  urea  produced  in  excess,  rather  than  a  mere  retention  of  ordinary 
amounts.  The  kidneys  may  become  so  choked  up  with  debris  that  com- 
plete suppression  of  urine  once  more  takes  place.  A  urinous  odor  is  given 
off  from  such  patients,  and  the  skin  may  become  covered  with  an  oleagi- 
nous sweat,  that  deposits  urea.  Unless  the  kidneys  quickly  resume 
their  function,  and  eliminate  large  quantities  of  urea,  patients  in  this 
pronounced  condition  of  intoxication  pass  from  bad  to  worse  and  die 
comatose,  after  the  entire  "typhoid"  has  lasted  four  days  at  the  utmost. 

It  may  be  instructive  to  compare  the  symptoms  of  cholera-typhoid. 


THE  CHOLERA  TYPHOID.  261 

as  described  by  Keinliardt  and  Leubuscher,  -n-itli  those  occurring  in  the 
urgemia  of  Bright's  disease  as  given  in  Gull's  report : 

Cholera  Typlioid. 

1.  Dull  pain  in  head. 

2.  Dimness  of  vision,  diplopia. 

3.  Giddiness,  drowsiness. 

4.  Slight  wandering  of  intellect. 

5.  Spasms,  tonic  or  clonic,  of  an  epileptic  form. 

6.  Pupil  normal. 

7.  Xo  paralysis. 

8.  Pulse  various,  sometimes  below  the  average;  commonly  quickened 
or  normal. 

9.  Temperature  of  the  skin  at  the  beginning  slightly  raised;  in  further 
course  normal;  with  extremities  cool. 

10.  Tongue  moist  and  furred,  and  later  in  the  disease,  dry  and  brown. 

11.  Vomiting,  which  ceased  when  the  cerebral  symptoms  became  more 
intense.     Evacuations  feculent;  their  consistency  various. 

12.  Frequent  excitement  and  irregular  rhythm  of  the  respiratory  move- 
ment, with  stertor. 

13.  Urine  suppressed  or  small  in  quantity,  and  albuminous. 

Ordinary  Urmmia. 

1.  Dullness  of  intellect,  sluggishness  of  manner. 

2.  Drowisness  preceding  coma,  and  more  or  less  stertor,  with  or  with- 
out 

3.  Convulsions,  These  symptoms  being  frequently  preceded  by  gid- 
diness, 

4.  Dimness  of  sight,  and 

5.  Pain  in  the  head. 

6.  Quiet  pulse. 

7.  Contracted,  or  normal  pupil, 

8.  No  paralysis. 

9.  Temperature  of  the  skin  natural. 

10.  Tongue  at  first  natural,  afterward  dry  and  brown. 

11.  Vomiting  an  early  symptom,  ceasing  when  the  brain  becomes  op- 
pressed. 

12.  Kespiration  frequently  with  stertor.  Khythm  irregular  and  quick- 
ened. 

13.  Urine  albuminous. 

In  uremic  cholera-typhoid  complete  suppression  of  urine  until  the 
fatal  issue  is  no  uncommon  occurrence.  Death  then  finds  the  bladder 
still  empty.  Generally,  however,  suppression  lasts  only  a  few  days,  to 
be  followed  by  the  appearance  of  a  small  quantity  of  highly  albuminous 
urine.  Still  later  increased  diuresis  may  alternate  with  a  diminished  flow 
or  a  return  of  suppression.  Such  oscillations  mark  the  uncertainty  attach- 
ing to  prognosis  in  the  condition  under  discussion. 

In  12  out  of  42  cases  carefully  watched  by  Drasche  there  was  complete 
suppressio  urin^e  until  death.  This  suppression  lasted  1  day  in  2  cases; 
2  days  in  4;  3  days  in  2;  4  days  in  2;  5  days  in  2;  6  days  in  1;  and  7 
days  in  1. 

In  11  of  the  42  cases  there  was  initial  suppression  lasting  2  days  in 
eight,  and  three  days  in  the  remaining  three  cases. 


262 


ASIATIC  CHOLERA. 


In  the  other  19  cases  there  was  diminished  renal  secretion,  but  no  sup- 
pression. 

The  frequency  of  cholera-typhoid  is  variable.  The  following  table 
published  by  Drasche  comprises  careful  observations  made  in  80.5  cases, 
all  occurring  in  the  epidemic  of  1855. 


Age  of  Patients. 

Number  of 
Patients. 

Number  of 
Typhoid  Cases. 

Percentage  of 
Typhoid  Cases. 

1  to  10  Tears 

8-,^ 

16.5 

248 

147 

78 

76 

59 

13 
45 
65 
39 
19 
27 
17 

40.6 

11   "  20      "     

27.2 

21  "  30      "     

26.2 

31  "  40      •'     

41  "  50      "       

26.5 
28.0 

51  "  60      "     

35.5 

61  "  88      "         

27.8 

Cholera-typhoid  is  more  apt  to  occur  in  women  than  in  men,  and  it  hap- 
haps  with  greatest  frequency  in  children.  Drasche  concludes  from  his 
personal  observations  that  not  quite  28  per  cent,  of  cholera  patients  develop 
this  condition.  It  should  be  stated,  however,  that  Drasche's  figures  differ 
from  those  of  other  observers.  Thus  Pfeuffer  saw  33.88  per  cent,  of  his 
cases  pass  into  t^^^hoid,  whereas  Liibstorff  reports  only  14. 28  per  cent. 
Other  ^Titers  give  still  other  figures.  All  in  all,  a  fair  average  may  be  com- 
puted at  about  25  per  cent. 

As  regards  the  time  of  development  of  cholera-tj^phoid,  it  is  also  rather 
variable.  Exact  records  of  42  cases  are  published  by  Drasche.  Counting 
from  the  first  characteristic  onset  of  an  attack  of  cholera,  the  tj^Dhoid  be- 
came manifest  after  from  two  to  11  days. 

Time  of  Occurrence  of  CJwlera-TypJioid. 
After  the  2d  clay  of  the  attack , 6  times. 


3d 
4th 
5th 
6th 
7th 
8th 
10th 

nth 


.12 

.10  " 

.  4  " 

.  4  '« 

3  '• 

.  1  time 

.  1  " 

.  1  " 


Inspection  of  the  above  tables  makes  it  appear  that  cholera-typhoid  is 
most  apt  to  arise  in  those  cases  where  the  attack  runs  a  rapid  course.  It 
is  the  graver  cases,  therefore,  that  furnish  the  largest  supply  of  typhoid 
affections.  When  reaction  takes  place  after  sudden  and  violent  symptoms 
it  is  often  a  typhoid  reaction,  although  as  has  been  previously  pointed  out 
a  healthy  reaction  is  by  no  means  out  of  the  question. 

When  cholera-tyijhoid  is  not  due  to  or  complicated  with  excessive 
uraemia,  final  convalescence  may  still  be  protracted  for  one  week,  two,  or 
even  three  weeks.  After  three  weeks,  unless  extraordinary  and  excep- 
tional complications  exist,  there  is  generally  perfect  restitution. 


CHOLERA  DURING  PREGNANCY  AND   CHILD-BED.  263 


CHAPTER    XXXII. 

PREGNANCY  AND  CHILDBED  AS  INFLUENCED  BY  CHOLERA, 

Although  strictly  speaking  pregnancy  is  not  a  complication  and  cer- 
tainly no  sequel  of  cholera,  it  seems  expedient  to  consider  the  subject  in 
this  connection,  and  a  brief  chapter  is  accordingly  devoted  to  it.  Cholera 
has  often  been  observed  in  pregnant  women;  it  does  not  appear,  as  has  been 
supposed  by  some  writers,  that  this  condition  creates  a  decided  predisposi- 
tion to  the  acquisition  of  the  disease.  Drasche  reports  having  observed 
39  pregnant  women  out  of  a  whole  number  of  858  female  cholera  patients. 
That  is  about  4. 5  per  cent. 

In  the  epidemic  of  1855  this  careful  observer  paid  particular  attention 
to  the  subject  under  consideration.  Among  431  female  cholera  patients, 
he  observed  35  in  a  pregnant  condition.     Of  these  there  were 

PregTiant  in  the  9th  month 5 

Sth  "  3 

7th  "  3 

6th  '^  6 

"  "        oth  "  2 

"  "        4th  "  3 

3d  "  2 

3d  "  3 

In  only  a  single  instance  was  a  living  child  born,  the  mother  making  a 
good  recovery  from  her  attack  of  cholera.  In  13  cases  a  dead  foetus  was 
born,  and  only  five  times  the  mothers  recovered.  In  11  cases  the  foetus 
was  not  extruded  by  abortion,  but  of  this  number  only  three  patients  re- 
covered with  living  products  of  conception.  Sixteen  of  the  pregnant 
women  died  and  nine  recovered.  It  was  observed  that  in  "  foudroyant" 
cases  an  almost  immediate  cessation  of  all  foetal  movements  and  cardiac 
pulsation  occurred. 

In  the  later  months  of  pregnancy  the  foetus  almost  invariably  died,  but 
in  the  earlier  months  life  was  at  times  maintained. 

Drasche's  observations  accord  so  well  with  those  of  later  writers  that 
it  is  unnecessary  to  adduce  further  evidence  regarding  the  fatality  to  both 
mother  and  child  of  attacks  of  cholera. 

Still,  it  is  noteworthy  that  children  have  at  times  been  born  and  re- 
mained alive,  the  mother  succumbing  to  the  progi'ess  of  the  disease  in 
childbed.  It  has  never  been  observed  that  a  child  was  born  actually 
suffering  from  cholera,  even  when  the  mother  was  almost  dead  of  the  dis- 
ease at  the  time  of  birth. 

Whether  the  disease  is  really  communicable  from  mother  to  child 


264 


ASIATIC  CHOLERA. 


through  the  i)lacental  circulation  is  still  in  dispute,  opinions  being  about 
evenly  divided.  Kecent  investigations  have  not  furnished  us  with  new 
data  that  might  serve  to  elucidate  or  decide  the  problem. 

Mouchet '  claims  to  have  three  times  observed  the  characteristic  lesions 
known  as  psorenterie  in  the  fojtus. 

Dr.  Leale  ^  says: 

My  observations  during  the  months  of  July,  Augnst,  and  September,  1866,  of 
pregnant  women,  in  a  neighborhood  where  tlie  epidemic  prevailed,  caused  me  to 
conclude  that  the  intense  fear  of  being  exposed  to  tiie  disease,  without  really  hav- 
ing it,  may  produce  a  shock  sufficienfto  either  kill  the  foetus  in  utero  or  to  bring 
about  a  premature  delivery.  Also  that  an  attack  of  Asiatic  cholera,  from  its  vio- 
lence, may  suddenly  kill  the  unborn  child,  but  that,  if  the  mother  recovers,  she 
may  go  uiitil  the  end  of  the  ninth  month  of  pregnancy,  when  she  may  safely  be 
delivered  of  her  macerated  dead  child.  Also  that  there  are  other  women,  of  either 
the  delicate  or  robust  organization,  who  will  carry  a  child  until  the  end  of  the  term, 
notwithstanding  the  most  fearful  commotions.  The  histories  of  our  wars  and 
epidemics  boldly  bring  this  class  into  view. 

Some  writers  have  claimed  that  the  amniotic  fluid  became  rapidly  re- 
absorbed in  cholera,  but  Drasche  and  other  authorities  dispute  the  truth 
of  this  statement.  The  unusual  violence  of  the  labor  pains  of  cholera 
patients  may  possibly  receive  its  explanation  from  the  general  spasms  ob- 
served in  the  muscular  system  of  such  sufferers.  In  this  connection  it 
is  not  without  interest  to  remember  that  in  non-pregnant  women,  uterine 
spasms  resembling  dysmenorrhoea,  or  even  simulating  labor  pains,  are  not 
infrequently  observed  very  soon  after  the  development  of  an  attack  of 
cholera. 

If  the  uterus  has  discharged  its  contents  and  the  mother  survives,  the 
organ  contracts  quickly  and  energetically,  and  rapid  involution  sets  in. 
Indeed,  it  has  at  times  been  found  impossible  to  detach  the  placenta  £)n 
account  of  the  rapidity  and  violence  of  the  uterine  contractions  follow- 
ing an  expulsion  of  the  child. 

Eegarding  childbed,  it  seems  that  the  early  days  of  Iving-in  afford  a 
relative  immimity  from  cholera,  the  attacks  being  far  more  frequent  be- 
tween the  first  and  second  weeks  than  immediately  after  delivery. 

It  Avill  be  readily  understood  that  whenever  cholera  complicates  puer- 
peral diseases,  the  patient's  chances  of  recovery  are  exceedingly  slim. 
'From  the  meager  data  that  are  found  scattered  through  the  literature  of 
the  subject  it  cannot  be  decided  whether  the  puerperal  state  creates  a  de- 
cided predisposition  to  the  acquisition  of  cholera.  Eeasoning  a^jriori  such 
a  predisposition  would  seem  to  be  quite  probable. 

'  These  de  Paris,  1867. 

-New  York  Medical  Jyuruul,  February  31, 1885. 


PART  FOURTH. 


THE  MOEBID  AIATOMY  AND  PATHOLOG- 
ICAL HISTOLOGY  or  CHOLERA. 


BY 


EDMUN^D    C.    WENDT,    M.D., 

OF  XEW  YORK. 


APPEARANCE  OF  THE  CADAVER.  267 


CHAPTER    XXXIII. 

MORBID  APPEARANCES  AFTER  DEATH  IN  COLLAPSE. 

General  Remarks. — In  giving  an  account  of  the  morbid  anatomy 
and  pathological  histology  of  cholera,  it  is  not  intended  to  describe  in 
detail  the  numerous  lesions  that  have  been  from  time  to  time  discovered 
in  connection  with  the  disease.  Only  those  changes  will  receive  consider- 
ation which,  being  most  commonly  found  in  the  post-mortem  examination 
of  cholera  bodies,  may  be  properly  regarded  as  belonging  to  the  disease. 

Yet  it  by  no  means  follows  that  even  the  more  common  lesions  must 
be  invariably  present  in  every  case.  Indeed,  if  we  remember  that  cholera 
sometimes  kills  within  a  few  hours  after  its  onset,  we  should  not  be  sur- 
prised to  find  that  even  some  of  those  changes  which  are  so  generally  en- 
countered as  to  appear  essential  to  the  disease  may,  in  exceptional  instances 
be  altogether  wanting.  This  does  not,  however,  apply  to  the  small  intes- 
tine, where  morbid  alterations  are  invariably  found,  no  matter  how  brief 
may  have  been  the  duration  of  the  attack. 

It  is  well  known  that  the  ordinary  autopsical  appearances  vary  in  accord- 
ance with  the  stage  of  the  disease  at  the  time  of  the  patient's  death. 
The  fatal  issue  occurs  most  frequently  in  collapse  or  during  the  period  of  re- 
action. And  it  is  precisely  during  collapse  and  after  reaction  that  the  morbid 
appearances  show  the  widest  difference.  Hence  it  will  facilitate  our  de- 
scription if  we  consider  the  in  separately  under  those  several  heads.  Never- 
theless, to  avoid  interrupting  the  narrative,  pathological  lesions  will  be 
exceptionally  described  under  the  first  heading  that,  strictly  speaking, 
should  be  grouped  under  the  second,  and  vice  versa. 

Appearance  of  the  Cadaver. — When  death  has  occurred  during  the 
collapse  of  cholera,  the  cadaver  presents  a  very  characteristic  appearance. 
Rigor  mortis  oc3urs  quickly,  is  always  well  marked  and  may  persist  for 
thirty  or  even  forty  hours.  The  entire  body  has  a  peculiarly  shrunken 
aspect.  Emaciation  may  be  extreme,  and  the  loss  of  subcutaneous  fat  is 
quite  pronounced,  except  in  those  rarer  cases  where  death  has  overtaken 
the  patient  after  the  disease  had  lasted  but  a  few  hours.  The  integument 
looks  wrinkled  and  has  a  ghastly  leaden  pallor,  with  deep  cyanosis  of  the 
distal  parts,  especially  the  finger-tips,  toes  and  ears.  Large  livid  cadaveric 
blotches  are  seen,  especially  at  the  dependent  parts  of  the  body. 

The  countenance  is  not  that  of  an  ordinary  corpse.  The  eyes  are 
deeply  sunken  in  the  bony  orbit,  and  generally  surrounded  with  wide 
bluish-black  rings;  the  chin  and  nose  are  sharp;  the  lips  look  purplish; 
the  malar  bones  project  prominently,  and  the  temples  have  an  exceedingly 
hollow  look.     All  the  features  seem  horribly  pinched.     In  a  word,  the 


2(^8  ASIATIC  CHOLERA. 

general  aspect  of  the  body  corresponds  in  all  essential  respects  to  the  ap- 
pearance of  the  patient  in  the  last  hours  of  life.  Cadaveric  decomposition 
is  long  delayed,  and  the  body  grows  cold  slowly. 

Post-mortem  Contractions  of  the  Muscles. — The  peculiar  phe- 
nomenon of  post-mortem  twitchings  and  contractions  of  the  muscles  must 
here  be  noticed.  Decided  movements  of  this  kind  have  been  repeatedly 
observed.  They  may  occur  several  minutes  or  houra  after  death.  Eich- 
liorst '  mentions  a  remarkable  case  in  which,,  three  hours  after  death,  mus- 
cular contractions  occurred  in  the  biceps,  and  finally  the  entire  muscle 
contracted,  producing  decided  flexion  of  the  forearm.  The  daughter  of 
the  deceased  patient  had  been  much  terrified  to  witness  this  apparent  re- 
suscitation, and  Eichhorst  being  hastily  summoned,  come  in  time  to  observe 
the  contractions,  but  not  the  alleged  return  to  life  of  the  man.  But  it 
was  even  to  the  physician  a  rather  startling  post-mortem  phenomenon. 
The  mouth  has  been  observed  to  open  and  shut  from  post-mortem  mus- 
cular contractions.  In  his  "  Lectures,"  Watvson  describes  these  singular 
occurrences  in  the  following  manner:  "  A  quarter  or  half  an  hour,  or  even 
longer,  after  the  breathing  had  ceased,  and  all  other  signs  of  animation 
had  departed,  slight,  tremulous,  spasmodic  twitchings  and  quiverings  and 
vermicular  motions  of  the  muscles  would  take  place,  and  even  distinct 
movements  of  the  limbs  in  consequence  of  these  spasms." 

Barlow '"  gives  an  account  of  these  remarkable  phenomena,  in  the  case 
of  a  man  who  had  quickly  succumbed  to  a  violent  attack  of  cholera.  The 
contractions  commenced  almost  immediately  after  death,  in  the  lower 
extremities,  where  the  patient  had  suffered  severe  cramps  during  his  life- 
time. "  Not  only  Avere  the  sartorius,  rectus,  vasti,  and  other  muscles 
thrown  into  violent  spasmodic  movements,  but  the  limbs  were  rotated 
forcibly  and  the  toes  were  frequently  bent.  The  motions  ceased  and-  re- 
turned; they  varied  also;  now  one  muscle  moved,  now  many.  Quite  as 
remarkable  were  the  movements  of  the  arm;  the  deltoid  and  biceps  mus- 
cles were  peculiarly  influenced;  occasionally  the  forearm  was  flexed  upon 
the  arm — flexed  completely;  and  when  I  straightened  it, which  I  did  several 
times,  its  position  was  recovered  instantly.  The  fingers  and  thumbs  were 
now  and  then  contracted,  and  at  times  the  thumbs  were  separately  moved. 
The  fibers  of  the  pectoral  muscles  were  often  in  full  action;  distinct  bun- 
dles of  them  were  seen  at  intervals  beneath  the  skin." 

In  his  article  on  cholera,  Stille^  says,  that  "  these  muscular  contractions 
succeed  one  another  in  a  regular  order,  beginning  in  one  lower  extremity 
and  extending  to  the  other,  then  to  the  upper  limbs,  and  finally  to  the 
face.  Their  degree  varies  from  a  slight  quivering  to  a  powerful  contraction, 
and  their  duration  is  from  a  minute  or  less  to  an  hour  and  a  quarter." 

This  is  in  complete  accord  with  Avhat  Drasche,''  in  his  well-known 
monograph,  described  as  early  as  1860.  '  Drasche  incidentally  alludes  to 
the  numerous  reports  and  stories  concerning  cases  of  apparent  death  and 
alleged  burials  of  living  patients,  especially  during  the  epidemics  of  I80O 
and  1831,  that  find  their  proper  explanation  in  these  post-mortem  phe- 
nomena. It  is  well,  therefore,  for  physicians  to  inform  the  attendants 
concerning  the  possibility  of  such  occurrences.     Drasche  himself  witnessed 

1  Article  on  cholera  in  Eulenburg's  Real-Encyclopaedie  der  gesammten  Heil- 
kunde,  1880. 

-  London  Medical  Gazette,  November,  1849. 

3  Pepper's  System  of  Practical  Medicine,  1885. 

■•Die  Epidemische  Cliolera.     Von  Di.  Anton  Drasche.     "Weir,  1860. 


POST-MORTEM   CONTRACTIONS  OF  THE  MUSCLES,  2G9 

the  most  fearful  confusion  and  consternation  among  those  surrounding  a 
dead  body,  on  the  sudden  appearance  of  muscular  contractions.  He  ex- 
plains the  occurrence  of  post-mortem  ejaculations  of  semen  through  mus- 
cular contractions  in  the  walls  of  the  vesicular  seminales. 

Mention  may  also  be  made  of  those  singular  caees  in  which  the  fore- 
arms become  so  contracted  as  to  cross  each  other,  giving  the  impression  of 
an  attitude  of  prayer.  Indeed  the  phenomenon  .has  been  so  interpreted 
by  some  of  the  older  writers,  and  the  last  moments  of  a  fast  fading  life 
have  been  held  to  be  coupled  with  the  involuntary  assumption  of  an  atti- 
tude of  prayer.  The  eyes  have  likewise  been  observed  to  open  and  move 
in  different  directions,  and  a  complete  turning  over  of  the  body  on  one 
side  has  been  credibly  described. 

Powerful  muscular  contractions  of  this  kind  have  been  at  times  ob- 
served in  other  diseases  as  well  as  in  cholera,  but  with  far  less  fre- 
quency. Stille  remarks  that  "  these  muscular  phenomena  after  death 
form  an  interesting  feature  in  the  history  of  cholera,  but  they  are  by  no 
means  peculiar  to  that  disease.  They  have  been  observed  in  other  diseases, 
and  especially  in  yellow  fever — an  affection  in  which  the  pathological  con- 
dition is  quite  unlike  that  of  cholera.  In  both  diseases  they  have  been 
manifested  in  robust  persons,  and  when  the  course  of  the  fatal  attack  Avas 
both  rapid  and  severe." 

He. also  alludes  to  the  experience  of  Dr.  Dowler,  of  New  Orleans,  who 
found  that  contractions  could  be  provoked  bj-  striking  the  muscles,  in 
rapidly  fatal  cases  of  yellow  fever.  Dr.  Dowler  also  witnessed  their  spon- 
taneous occurrence,  and  describes  a  noteworthy  instance  of  the  phenome- 
]ion  in  question  as  follows: 

"  Not  long  after  the  cessation  of  the  respiration  the  left  hand  was  car- 
ried by  a  regular  motion  to  the  throat,  and  then  to  the  crown  of  the  head; 
the  right  arm  followed  the  same  route  on  the  right  side;  the  left  arm  was 
then  carried  back  to  the  throat,  and  thence  to  the  breast,  reversing  all  its 
original  motions,  and  finally  the  right  hand  and  arm  did  exactly  the 
same. " 

Drasche  has  pointed  out  that  these  phenomena  never  happen  in  patients 
Avho  have  died  in  the  typhoid  stage  of  cholera.  It  is  not  impossible  that 
the  ante  and  post  mortem  muscular  movements  may  in  some  measure 
account  for  the  elevation  of  temperature  which  takes  place  after  death 
from  cholera;  an  elevation,  it  will  be  remembered,  that  may  amount  to 
over  four  degrees  Fahrenheit.      At 

The  Necropsy  the  marked  dryness  of  the  subcutaneous  connective- 
tissue,  as  well  as  the  dryness  and  deep  reddish-brown  color  of  the  muscles, 
are  at  once  apparent.  The  abdominal  viscera  likewise  appear  dry,  and 
sometimes  seem  almost  pressed  together,  having  shrunk  deeply  back  into 
the  abdominal  cavity.  Of  course  this  is  not  seen  in  those  cases  where  the 
intestines  contain  an  overabundance  of  fluid.  Our  attention  is  naturally 
first  directed  to  the  condition  of  the  alimentary  canal.  The  serous  surface 
of  the  small  intestine  looks  rosy  or  purplish,  that  of  the  stomach  and  colon 
normally  pale.  There  is  no  distension  from  gas,  but  fluid  may  be  found, 
especially  in  the  ileum,  in  greater  or  less  abundance.  Often  the  intestines 
have  a  flabby,  sodden  appearance. 

The  Peritoneum,  and  especially  the  serous  covering  of  the  intestine, 
is  either  quite  dry,  or  else  it  appears  coated  with  a  thin  film  of  a  viscid  al- 
buminous substance,  that  on  being  rubbed  produces  a  soapy  scum  or  lather. 
Microscopically  examined,  this  substance  is  found  to  consist  principally 


270  ASIATIC  CHOLERA. 

of  desquamated  endothelial  cells,  wliich  have  undergone  granular  degen- 
eratioTi  or  mucoid  metamorphosis.' 

The  Pharynx  and  CEsophagus  are  sometimes  found  almost  normal, 
but  oftener  the}'  show  more  or  less  congestion  of  the  mucous  membrane, 
with  extravasations  and.  ecchymoses  varying  in  extent  and  degree.  The 
usual  slimy  coating  is  replaced  by  a  dry  appearance  of  the  inner  surface. 
Only  exceptionally  do  we  find  a  creamy  substance  deposited  in  a  thin  layer 
upon  the  lower  segment  of  the  oesophagus. 

The  Stomach  is  often,  yet  by  no  means  always,  hyi^ersmic.  But  the 
hypera^mia  rarely  extends  to  the  serous  coat.  Its  mucous  surface  is  coated 
with  a  thick  layer  of  viscid  mucus,  that,  owing  to  the  presence  of  blood, 
sometimes  assumes  a  brownish-red  or  even  inky  look.  Bilious  contents  of 
the  stomach  are  rarely  seen.  Sometimes  in  jjlace  of  being  hypereemic  the 
gastric  mucosa  looks  abnormally  pale.  It  is  a  fact  that  the  mucous  mem- 
brane covering  the  fundus  is,  as  a  rule,  found  to  be  more  or  less  softened 
and  relaxed.  But  m  spite  of  the  writings  of  Rayer,"  Briquet  and  Mignot,^ 
Tholozan,^  and  others,  this  softening  must  be  regarded  as  of  post-mortem 
origin.  Tholozan  has  also  described  a  gastric  "  psorenterie,"  brought  about 
by  the  appearance  of  small,  oval,  whitish  and  friable  projections  upon  the 
inner  surface  of  the  mucosa.  Most  observers  fail  to  mention  appearances 
of  this  kind. 

The  Small  Intestine,  in  addition  to  the  previously  noticed  subserous 
vascularity  that  imparts  to  the  outer  coat  its  rosy  tint,  often  shows  more 
or  less  congestive  swelling  of  the  mucosa.  But  at  times  the  miicous  mem- 
brane appears  normally  or  even  unnaturally  pale.  When  hyperemia  is 
well-marked  and  bloody  extravasations  have  occurred,  these  conditions  are 
observed  to  be  most  pronounced  in  the  ileum,  especially  as  we  approach 
the  ileo-c»cal  valve.  Koch,  who  has  carefully  studied  the  condition  of- the 
intestines  in  cholera  corpses,  finds  the  usual  text-book  description  of  their 
appearance  insufficient  or  faulty.  In  his  address  on  Cholera  and  its  Ba- 
cillus, delivered  at  Berlin,  he  says: 

There  were  cases  in  which  the  lower  section  of  the  small  intestine  was  colored 
dark  brownish  red,  most  intensely  immediatelj'^  above  the  ileo-cajcal  valve,  less  so 
higher  up,  the  mucous  membrane  being  studded  with  superficial  haemorrhages. 
In  manj^  cases  the  mucous  membrane  was  even  superficially  necrosed,  and  showed 
diphtheritic  coatings.  Corresponding  to  this,  the  contents  of  tlie  intestine  were 
not  a  rice-watery  colorless  liquid,  but  a  bloody,  ichoi-ous,  stinking  tluid. 

Other  cases  showed  a  gradual  transition  to  less  marked  modifications.  The 
redness  was  less  intense  in  them,  and  finally  existed  only  in  patches;  and  these 
were  followed  by  cases  in  which  only  the  borders  of  the  follicles  and  Peyer's  glands 
were  reddened.  This  last-mentioned  item  affords  a  very  characteristic  appear- 
ance, which  does  not  occur  in  otlier  affections  of  the  intestines,  and  is  quite  pecul- 
iar to  cholera.  In  comparatively  very  few  cases,  however,  the  mucous  membrane 
was  ver3^  Uttle  clianged.  It  looked  somewhat  swollen  and  less  transparent  in  the 
surface-layei-s;  the  solitary  follicles  and  Peyer's  glands  were  strongly  prominent. 
The  whole  mucous  membrane  was  slightly  rose-colored,  but  there  was  nowhere 
any  capillarj'  haemorrhage.  In  these  cases  the  contents  of  the  intestine  also 
looked  colorless,  but  thej'  were  by  no  means  always  like  rice-water,  but  would  be 
generallj^  better  compared  to  gruel.  Only  in  a  few  cases  have  I  seen  that  the 
contents  of  the  intestine  were  purely  watery  and  mucous,  and  contained  compara- 
tively few  flakes. 

'  Sti-aus,  Legons  sur  I'anatomie  Pathol,  du  Cholera.  Le  Progres  Medical,  De- 
cember 13,  1884.  '■^  Recherches  anatomiques  sur  le  cholera.     Paris,  1832. 

^  Traite  pratique  et  analji:ique  du  cholera.     Paris,  1850. 

■*  Recherches  sur  quelques  points  d'anatomie  et  de  physiologie  pathologiques 
du  cholera,  Paris. 


THE  SMALL  INTESTINE.  271 

Macnamara  says  that  he  has  frequently  seen  cases  in  which  "the  mucous 
surface  of  the  intestinal  canal,  like  that  of  the  stomach,  is  pale  and  ex- 
sanguine from  one  end  to  the  other."  Concerning  the  congested  portions, 
the  same  author  writes:  "If  a  portion  of  the  injected  intestine  be  placed 
iinder  the  microscope,  a  half-inch  power  used,  and  pressure  made  on  the 
covering  glass,  it  will  be  observed  that  the  blood  contained  in  the  congested 
vessels  is  not  squeezed  uniformly  out  of  the  veins,  but  breaks  off  into 
little  masses,  reminding  one  of  the  detached  patches  of  mercury  seen  at 
times  in  a  broken  thermometer,  or  other  narrow  glass  tube,  conveying  the 
idea  that  the  blood  in  the  vessels,  although  not  formed  into  a  clot,  has 
become  thick  and  tenacious." 

Stille  believes  that  "the  general  paleness  of  the  intestinal  mucous  mem- 
Tjrane  in  the  stage  of  collapse,  and  its  congestive  redness  whenever  the  signs 
of  reaction  have  existed  before  death,  have  a  very  important  bearing  upon 
the  pathology  of  this  disease,  for  they  demonstrate  conclusively  that  the 
gastro-intestinal  evacuations  in  cholera  have  no  relation  whatever  to  inflam- 
mation. On  the  other  hand,  they  render  it  altogether  probable  that  the 
serous  flux  is  in  the  nature  of  a  sweat,  an  intestinal  ephidrosis. " 

This  view  evidently  accords  Avith  some  observations  made  by  Sutton,* 
which  were,  however,  too  limited  to  justify  any  such  wide  generalization. 

Numerous  examinations  by  other  observers  show  that  synchronously 
witli  the  immense  serous  effusion  there  constantly  occur  changes  of  a 
distinctly  inflammatory  character.  If  we  are  to  believe  Koch,  they  must 
be  regarded  in  the  light  of  a  specific  process  due  to  a  bacillary  invasion. 
Hyperemia,  small-cellular  infiltration,  swelling  and  granular  degeneration 
of  glandular  epithelium,  ecchymosis,  hgemorrhage  and  even  necrosis — all 
these  commonly  observed  changes  clearly  show  that  the  intestines  in  cholera 
are  in  a  condition  of  acute  specific  inflammation.  It  does  not  appear  pos- 
sible, therefore,  that  the  "  serous  flux"  has  no  other  significance  than  that 
of  a  non-inflammatory  intestinal  sweat. 

At  the  recent  English  debate  on  cholera.  Dr.  Pye-Smith  ^  compared  the 
rice-water  discharge  to  the  paralytic  secretion  wliich  occuiTed  after  division 
of  all  the  nerves  supplying  a  portion  of  the  gut.  He  also  held  that  the 
intestinal  lesions  of  cholera  were  of  a  non-inflammatory  kind.  But  his 
views  were  evidently  not  shared  by  the  majority  of  those  who  participated 
in  the  discussion.  Sutton  himself  has  stated  that  even  when  "the  mucous 
membrane  was  pale  throughout  the  entire  intestine,  the  valvul^e  conniventes 
looked  swollen  and  oedematous.  The  solitary  glands  were  very  distinct 
and  prominent.  "  In  imperfect  reaction  be  found  the  mucous  membrane 
very  much  congested  and  ecchymosed."  The  congested  portions  were 
sometimes  granular,  and  apparently  denuded  of  epithelium.  The  mucous 
surface  had  often  a  dark  port-wine  color,  due  to  the  extravasated  blood  and 
the  hyperemia,  and  here  and  there  the  surface  was  covered  with  a  dirty 
gray  membranous  substance,  likened  to  a  diphtheritic  deposit.  I  have, 
however,  seen  no  decided  false  riiembrane,  such  as  could  be  peeled  off,  as 
in  diphtheria.  The  surface  was  also  occasionally  bile-stained,  and  the 
greenish-yellow  color  of  the  bile  and  the  deep  red  color  of  the  congested 
surface  presented  a  very  striking  appearance.  The  solitary  glands  were 
very  prominent,  and  in  some  cases  apparently  enlarged." 

The  inflammatory  changes  as  described  by  Kelsch  and  Kenaut '  are 

'  London  Hospital  Clinical  Lectures  and  Reports,  vol.  iv. 

«  The  Britisli  Medical  Journal,  April  4,  1885. 

2  Note  sur  les  alterations  histologiques  de  I'mtestin,  etc.  Progres  medical,  1873. 


272  ASIATIC  CHOLERA. 

distinct  and  unmistakable.  These  writers  mention  especially  the  small 
cellular  infiltration  of  the  mucous  and  submucous  coats.  Leucocytes  of 
emigration  were  also  seen  beneath  the  serous  coating  by  tliese  observers. 

This  round-celled  infiltration  may  affect  the  solitary  follicles  and  Peyer's 
patches  to  such  an  extent  that  a  striking  similarity  to  typhoid  intestines 
results.     Rudnew  '  was  struck  by  this  peculiarity  as  long  ago  as  18G6. 

EpifheUal  Desquamation  of  Cholera  Intestines. — A  few  words  must 
here  be  devoted  to  the  mooted  question  regarding  the  occurrence  and 
significance  of  extensive  epithelial  desquamation  in  the  intestinal  canal  of 
choleraics.  Formerly  it  was  very  generally  believed  to  be  one  of  the  most 
important,  if  not  the  most  important  pathological  phenomenon  of  the 
Avhole  disease.  And  even  at  the  present  day  there  are  those  who  uphold 
such  views.  Thus  Dr.  Maclagan,  at  the  recent  discussion  on  cholera  before 
the  Royal  Medical  and  Chirurgical  Society/  distinctly  asserted  that  the 
shedding  of  the  epithelium  was  the  characteristic  lesion  of  cholera,  and 
that  the  mucous  membrane  of  the  alimentary  tract  Avas  the  nidus  of  the 
poison. 

The  intestinal  villi  and  even  the  follicles  have  been  repeatedly 
found  to  be  deprived  of  their  epithelium,  and  shreds  of  exfoliated  epithelial 
membrane,  forming  the  "rice-water  granules,"  have  then  always  been  dis- 
covered within  the  intestinal  lumen,  throughout  its  entire  extent.  Nie- 
meyer  likened  this  condition  to  that  of  a  portion  of  integument,  from 
■which  the  epidermis  had  been  raised  by  a  burn.  ]\Iacnamara  often  noticed 
a  considerable  portion  of  the  epithelium  still  adhering  to  the  walls  of  the 
intestines.  But  in  all  liis  published  Avritings,  excepting  only  his  last  article 
on  cholera  in  Quain's  Dictionary,  he  expresses  the  conviction  that  this 
separation  of  epithelium,  was  to  a  great  extent  an  ante-mortem  occurrence. 
Referring  to  the  granular  disintegration  of  the  individual  epithelial  cells, 
he  admits  that  the  change  differs  in  no  way  from  what  is  observed  in  or- 
dinary decomposition.  But,  he  says,  "  there  is,  nevertheless,  this  most 
vitally  important  distinction  between  the  two — the  decomposition,  or 
molecular  change  in  the  cells,  due  to  cliolera,  commences  when  the  patient 
is  in  possession  of  life  and  vigor;  it  is  the  rapid  death  and  destruction  of 
intestinal  epithelium  during  life  which  is  the  characteristic  feature  of  this 
disease,  and  renders  it  so  deadly."  Besides  this  the  epithelium  of  the 
nasal  passages  and  mouth,  of  the  pharAiix  and  oesophagus,  may  be  shed  in 
large  patches,  or  may  appear  almost  completely  destroyed,  and  this  de- 
struction is  also  seen  in  epithelium  found  elsewhere  in  the  body,  as  in  the 
kidneys,  and  other  parenchymatous  organs.  It  is  curious  to  note  that 
Macnamara  for  a  long  time  did  not  hesitate  to  ascribe  this  extensive  epi- 
thelial alteration  to  post-mortem  changes,  in  all  the  organs  of  the  body  save 
the  intestines,  where  of  all  other  places,  it  would  be  most  likely  to  occur. 
There  is  no  doubt,  in  the  opinion  of  the  editor,  that  the  intestinal  ex- 
foliation is  mainly  but  not  entirely  due  to  cadaveric  changes.  Cohnheim 
and  Ills  followers  went  further  than  this,  and  asserted  it  to  be  solely  due 
to  cadaveric  decomposition. 

Flint"*  almost  completely  agrees  with  Cohnheim  stating  ''that  there  is 
no  ground  for  assuming  that  during  life  an  extensive  desquamation  of  the 
epithelium  takes  place. "     At  the  ju'csent  writing  Macnamara  and  many 

'  Quoted  bv  Straus  in  le  Progres  medical,  December  13,  1884. 

•  The  Briti'sli  Medical  Journal,  April  4,  1885. 

^  A  Treatise  on  the  Principles  and  Practise  of  Medicine.     1881,  p.p.  554 


THE  LARGE  INTESTINE.  273 

other  competent  authors  entertain  the  view  tliat  such  desquamation  is  largely 
the  result  of  post-mortem  change^  in  Avhich  opinion  the  editor  has  already 
expressed  his  concun'ence.  Apropos  of  this  subject  we  may  be  permitted 
to  here  introduce  the  following  quotation  from  Stille: 

As  long  ago  as  the  first  American  epidemic  of  cholera  (1832-35)  Dr.  W.  E. 
Horner,  Professor  of  Anatomy  in  the  University  of  PennsyRania,  described  an 
exfoliation  of  the  epithelial  lining  of  the  alimentary  canal,  whereby  the  exti*emi- 
ties  of  the  venous  system  of  the  part  are  denuded,  as  being  characteristic  of  cholera 
alone.  In  1849,  Dr.  Samuel  Jac-kson,  Professor  of  the  Institutes  of  Medicine,  and 
Dr.  John  Neill,  Demonsti'ator  of  Anatomy  in  the  University,  in  conjunction  with 
Dr.  William  Pepper  and  Dr.  Pavil  B.  Goddard,  presented  a  repoi-t  to  the  College 
of  Physicians  of  Philadelphia,  in  which  they  too  showed  that  the  epithelial  layei 
of  the  intestinal  mucous  membrane  was  either  entirely  removed  or  was  detached, 
adhering  loosely.  This  important  fact — the  most  important,  perhaps,  in  the 
mechanism  of  cholera — was  confirmed  seventeen  years  later  by  the  eminent  pa- 
thologist Dr.  Lionel  S.  Beale,'  who,  when  referring  to  "  tlie  remarkable  chai'ac- 
ters  of  the  matter  discharged  from  the  intestinal  tube,  and  to  the  fact  that  the 
small  intestines  almost  always  ?ontain  a  considerable  quantity  of  pale  almost 
colorless  gruel,  rice,  or  cream-like  matter,"  added:  "This  has  been  pi-oved  to 
consist  almost  entirely  of  columnar  epithelium,  and  in  very  many  cases  large  flakes 
can  be  found,  consisting  of  several  uninjured  epithelial  sheaths  of  the  villi.  .  .  . 
In  bad  cases  it  is  probable  that  almost  every  villus,  from  the  pylorus  to  the  Uio- 
cajcal  valve,  has  been  stripped  of  its  epithelial  coating  during  life.  .  .  .  These 
impoi'tant  organs,  the  villi,  are,  in  a  veiy  bad  case,  all  or  nearlj^  all  left  bare,  and  a 
very  essential  part  of  what  constitutes  tlie  absorbing  apparatus  is  completely  de- 
stroyed. .  .  .  It  is  probable  that  the  extent  of  this  process  of  denudation  deter- 
mines the  severity  or  mildness  of  the  attack.  ...  It  seems  probable  also  that 
the  epithelium  may  become  detached  in  consequence  of  the  almost  complete  ces- 
sation of  the  circulation  in  the  capillaries  beneath,  but  the  death  of  the  cells  may 
occur  in  consequence  of  their  being  exposed  to  the  influence  of  certain  matters 
in  the  intestine  or  in  the  blood,  in  which  case  they  would  simply  fall  off. 

The  glandular  structures  of  the  small  intestine,  as  already  intimated, 
show  varying  degrees  of  morbid  change.  The  solitary  follicles  are  uniformly 
enlarged,  opaque,  hard,  and  seemingly  filled  Avith  an  amorphous  finely 
granular  exudation  (Keinhardt  and  Leubuscher)."  Peyers  patches,  and 
Brunners  glands  are  found  to  be  similarly  affected.  Peyer's  patches  also 
show  more  or  less  distinctly  the  congestion  already  alluded  to  in  the  de- 
scription given  by  Koch.  They  have  at  times  been  found  in  a  condition 
of  sviperficial  ulceration,  not  unlike  that  of  typhoid  fever.  On  account  of 
the  great  prominence  of  the  solitary  follicles,  the  French  speak  of  the  in- 
testinal appearance  in  cholera  as  o,  psorenterie.  Microscopically  examined, 
the  almost  complete  absence  of  the  epithelial  lining  of  the  mucosa  is  readily 
observed.  In  addition  there  is  constantly  seen  a  small  cellular  infiltration 
of  the  mucous  membrane  that,  in  spite  of  the  contrary  statement  of  Kelsch, 
only  exceptionally  extends  below  the  muscularis  mucosae.  But  this  does 
not  apply  to  the  lower  end  of  the  ileum,  where  the  inflammatory  infiltration 
is  seen  to  have  penetrated  far  into  the  submucous  tissue.  Straus'  character- 
izes the  intestinal  lesions  of  cholera  as  an  "  acute  desquamative  enteritis." 

The  Large  Intestine  is  frequently  found  in  a  collapsed  condition. 
There  occur  in  it  scarcely  any  constant  changes.  Indeed  it  is  a  singular 
circumstance  that  the  colon  has  at  times  presented  a  perfectly  healthy  ap- 
pearance. Generally,  however,  the  solitary  follicles  and  agminated  glands 
are  seen  to  be  swollen,  hard,  opaque  and  filled  with  fluid  or  sticky  contents. 

'  Medical  Times  and  Gazette,  August,  1866. 
^  Virchow's  Archiv,  vol.  xi.,  1849. 
^  Le  Progres  Medical,  December,  13,  1884. 
18 


274  ASIATIC  CHOLERA. 

Their  prominence  gives  rise  to  the  same  condition  oi  2'>sorenfcne,  just  men- 
tioned in  connection  with  the  small  intestine.  But  an  inflammatory  infil- 
tration of  round  cells  is  not  observable  in  the  coats  of  the  large  intestine. 

The  Mesenteric  Glands  are  moderately  enlarged,  soft,  and  somewhat 
congested.  Virchow  found  in  them  an  exudation  which  looked  white  and 
granular,  resembling  the  milt  of  herrings.  Macnamara  asserts  that  this 
whitish  appearance  is  due  to  molecular  matter  carried  by  the  lacteals  from 
the  intestine  to  the  lymph-glands.  Straus  found  the  mesenteric  glands 
sometimes  normal  in  size  and  appearance,  at  other  times  slightly  increased 
in  volume  and  hypera?mic. 

The  Thoracic  Duct  and  lympliatics  generally  are  found  empty,  and 
show  no  noteworthy  alteration. 

The  Spleen  is  commonly  found  small  and  shrunken,  with  a  wrinkled 
capsule,  and  flabby  parenchyma.  Buhl  observed  a  milky  fluid  -filling  the 
Malpighian  bodies,  and  Reinhardt  and  Leubuscher  noticed  h}q3era5mia  and 
extravasations.  Infarctions  have  at  times  been  discovered.  Straus  em- 
phasizes the  point  that,  contrary  to  Avhat  is  observed  in  most  infectious 
diseases,  the  cholera  spleen  is  diminished  in  size,  shriveled,  and  of  firm 
consistency  rather  than  soft  and  pulpy. ' 

The  Liver  is  rather  small,  pale  brown,  flacid  and  quite  anaemic,  only  the 
portal  veins  being  at  times  filled  with  dark  blood.  The  acinous  markings 
are  generally  very  indistinct.  Straus  ^  says  that  the  liver  alwa^'s  presented 
to  the  naked  eye  grayish  du'ty  yellow  spots  scattered  over  the  surface.  They 
were  also  seen  in  the  substance  of  the  organ.  On  microscopical  examina- 
tion the  trabecule  of  the  hepatic  cells  were  found  somewhat  separated  from 
each  other,  and  here  and  there  had  in  part  lost  their  radiated  arrangement; 
the  capillaries  were  distended  and  filled  with  red  blood  globules.  The 
hepatic  cells  themselves  were  granular  and  presented  a  condition  of  protein- 
ous  infiltration,  much  less  marked,  however,  than  that  of  the  renal  epithe- 
lium. A  certain  number  of  the  nuclei  were  increased  in  size  sometimes  to 
double  that  of  the  normal.    The  epithelium  of  the  hepatic  ducts  was  intact. 

MM.  Hanot  and  Gilbert  have  recently  discovered  in  certain  cases  little 
islets  in  the  hepatic  lobules  which  are  incapable  of  receiving  any  staining.  ^ 
These  islets  are  formed  of  swollen  hepatic  cells,  with  transparent  glassy- 
looking  protoplasm,  but  with  nuclei  normally  stained.  They  propose 
for  this  alteration  the  name  of  transparent  tumefaction. 

MM.  Xicati  and  Eietsch  ^  have  also  described  hepatic  changes  which 
they  believe  to  be  always  present  in  cholera.  They  say  that  the  liver  was 
more  or  less  atrophied,  the  lobular  contours  were  effaced,  and  the  cellular 
trabecule  within  the  lobules  were  markedly  widened.  They  also  allude  to 
the  distention  of  the  gall  bladder  and  of  the  cystic,  hepatic  and  common 
ducts;  the  latter  was  narrowed  as  it  entered  the  intestine,  so  that  very  consid- 
erable force  was  sometimes  necessary  to  cause  the  bile  to  pass  through.  Crys- 
talline needles  were  found  in  the  blood  of  the  vena  caA'a,  and  the  fresh  liver 
presented  on  section  an  abundance  of  fat  drops  and  colorless  crystalline 
accretions.  The  amount  of  glycogen  in  the  liver  Avas  considerabh^  dimin- 
ished. In  individuals  dead  in  the  algid  stage  the  bile  was  inspissated  and 
black  in  color.     There  was  often  a  total  absence  of  bile  in  the  intestine. 

The  gall-bladder,  as  just  described  by  Xicati  and  Eietsch,  is  filled,  often 

'  Le  Progres  Medical,  February  14,  1885. 

"'  Ibid. 

^Comptes  Rendus  de  la  Soc.  de  Biologie,  No.  41,  1884,  p.  685. 

■'La  Seinaine  Medicale,  No.  41,  1884. 


THE   KIDNEYS.  975 

to  distention,  with  thin  brownish  or  green  fluid.  Eeinhardt  and  Leu- 
busclier  liave  observed  pus  and  detached  epithehum  mixed  Avith  its  biliary 
contents. 

The  Kidneys. — Aside  from  the  intestinal  lesions  of  cholera  the  most 
important  morbid  alterations  are  found  in  the  kidneys.  Lebert  has  made 
a  careful  study  of  these  organs  as  affected  by  the  disease,  and  Virchow  as 
Avell  as  Eeinhardt  and  Leubuscher  have  also  paid  special  attention  to  them. 

Beginning  with  active  congestion,  the  tubules  quickly  undergo  cloudy 
swelling  that  eventuates  in  fatty  degeneration. 

In  cases  that  have  proved  fatal  within  a  few  hours  the  kidneys  show 
only  moderate  hyperemia,  principalh^  in  the  venules  near  the  cortex,  and 
incipient  cloudy  swelling  of  the  tubular  epithelium. 

The  extensive  desquamation  of  renal  epithelium,  and  plugging  up  of 
the  lumina  of  many  tubules,  which  have  been  described  by  some  writers 
as  characterizing  this  early  stage,  is  certainly  due  in  most  cases  to  post- 
mortem changes. 

When  the  disease  has  lasted  twenty  hours  or  more,  the  kidneys  show 
parenchymatous  changes  in  varying  degrees  of  intensity.  Still  later  fatty 
degeneration  may  become  quite  pronounced.  The  affection  is  irregularly 
disseminated  throughout  the  diseased  organs,  in  such  a  way  that  healthy 
tubules  are  found  side  by  side  with  others  far  advanced  in  degeneration. 

Lebert  says  regarding  the  morbid  affection  of  the  kidneys:  "  These 
organs  may  early  take  part  in  the  process  of  the  disease.  Even  in  cases  in 
which  death  occurred  in  from  sixteen  to  twenty-four  hours  after  the  at- 
tack, I  have  always  observed  an  increase  in  the  volume  of  the  kidneys.  At 
the  same  time  I  found  them  generally  filled  with  blood,  in  the  form  of 
stripes  and  punctated  injection  in  both  the  cortical  and  medullary  sub- 
stances, and  on  the  surface  in  more  star-shaped  and  marbled  spots,  with 
numerous  and  thick  anastomoses.  The  superficial  intercanalicular  vessels 
and  capillaries  of  the  ^lalpighian  glomeruli  also  shared  in  this  condition 
of  congestion,  and  ecchymoses  in  different  regions  were  likewise  not  infre- 
quent. Even  in  cases  of  death  in  the  second  half  of  the  first  day,  I  have 
often  found  the  cortical  substance  of  the  kidneys  in  an  unmistakable  con- 
dition of  commencing  decoloration,  extending  even  from  the  surface  deep 
down  into  the  pyramids.  I  have  also  often  seen  the  capsules  abnormally 
adherent  at  this  time.  The  microscope  reveals  at  this  early  stage  a  re- 
markable epithelial  proliferation  in  the  urinary  tubules  with  cloudy  swell- 
ing of  the  cells,  the  contents  of  Avhich,  consisting  of  numerous  albuminoid 
granules,  may  be  dissolved  by  acetic  acid.  Xow  and  then  I  have  also 
found,  as  early  as  at  the  end  of  the  first  day,  distinct  transparent  cylinders 
in  the  interior  of  the  urinary  canals.  The  kidneys,  therefore,  are  decidedly 
affected  on  the  very  first  day  of  a  pronounced  attack  of  cholera." 

The  Bladder  is  generally  found  empty  and  collapsed.  At  times  its 
mucous  surface  shows  a  creamy  coating  of  degenerated  and  detached 
epthelium.  Hyperiemia  about  the  neck  of  the  bladder  is  occasionally 
present. 

The  Ureters  are  frequently  hyperaemic,  and  likewise  have  a  some- 
what creamy  coating,  that  has  no  special  significance.  The  aj^pearance 
of  the  renal  pelvis  and  calyces  has  already  been  mentioned. 

The  Uterus  commonly  contains  sanguinolent  mucous  or  pure  blood 
in  clots.  Its  mucous  membrane  is  often  much  congested,  and  mottled 
with  spots  of  extravasation,  varying  in  size  from  a  pin's  head  to  large 
blotches,  that  may  seem  to  cover  nearly  the  entire  surface. 


276  ASIATIC  CHOLERA. 

Infarctions,  with  their  broad  base  turned  inward,  have  been  repeatedly- 
seen  in  the  muscular  parenchyma  of  the  Avomb. 

The  Ovaries  show  more  or  less  hyperaemia  that  seems  to  keep  pace 
with  the  same  condition  of  the  uterus.  Bloody  extravasations  have  been 
found  in  the  substance  of  these  organs. 

The  Vagina  exhibits  the  same  tendency  to  bloody  sitffusion  and 
ecchymosis  that  is  Avitnessed  in  connection  with  the  other  portions  of  the 
female  generative  apparatus. 

The  Pericardium,  and  especially  the  Pleura,  looks  dry,  but  often 
has  a  thin  coating  that  is  in  all  respects  similar  to  what  has  been  already- 
described  as  covering  the  peritoneum.  Ecchymoses  are  a  frequent  occur- 
rence, principally  in  the  dependent  portions. 

The  Heart  is  firmly  contracted  in  its  left  compartments,  less  so  on 
the  right  side. 

The  left  ventricle,  and  at  times  the  entire  organ,  contains  little  or  no 
blood.  Usually,  however,  the  right  auricle  and  ventricle  are  filled  with 
dark  clotted  blood.  A  separation  of  bulfy  clots  does  not  invariably  hap- 
pen, but  it  is  the  rule  nevertheless. 

The  muscular  substance  of  the  heart  is  firm,  red,  and  hard.  Fatty 
degeneration  is  not  present. 

Buhl '  has  ascertained  that  the  loss  in  water  is  less  in  the  cardiac  mus- 
cle than  in  the  other  muscles  of  the  body.  Heart  muscle  also  contains  a 
smaller  proportion  of  urea. 

Tlie  endocardium  sometimes  shows  a  few  ecchymoses.  Eegarding  the 
blood-vesmls,  it  is  at  once  apparent  that  there  is  arterial  depletion  and 
venous  filling,  though  even  the  latter  is  but  rarely  pronounced,  owing  to  the 
reduction  of  the  entire  volume  of  blood.  The  perivascular  deposition  of 
reddish-brown  pigment  is,  according  to  Buhl,  a  constant  occurrence  in 
cholera.     Pigment  is  also  found  in  the  Avails  of  the  vessels. 

Lehmann '"  and  especially  Schmidt,^  have  made  careful  studies  regarding 
the 

Condition  of  the  Blood  in  cholera.  Schmidt  ascertained  that  the  in- 
spissation  of  the  blood  Avas  at  its  height  about  thirty-six  hours  after  the 
onset  of  the  pronounced  disease. 

At  that  time  the  proportion  of  solids  may  be  one  a^d  a  half  times 
greater  than  normal.  This  remarkable  increase  belongs  chiefly  to  the 
organic  ingredients  of  the  blood.  80  far  as  the  solids  are  concerned  the 
loss  through  transudation  mainly  belongs  to  the  sodium  chloride.  Hence 
the  potash  salts  and  phosphates  appear  relati\'ely  increased.  Urea  also 
accumulates  in  the  blood,  OAving  to  the  renal  disturbances  aboA^e  described. 
NeA'ertheless,  Lebert  was  unable  to  demonstrate  in  the  blood  of  patients 
dying  in  the  typhoid  stage,  an  increase  of  either  urea  or  carbonate  of  am- 
monia. 

Quite  recently  M.  Straus  has  published  an  interesting  account  of  a  series 
of  investigations  regarding  the  blood  in  cholera,'  of  Avhicli  the  folloAving  is 
a  summary:  The  gross  appearance  of  the  blood  after  standing  for  about 
twenty-four  hours  is  very  similar  to  that  of  infectious  diseases  or  of 
asphyxia.  It  is  of  a  deep  black  color,  and  covered  by  a  layer  of  clear,  not 
coagulated,  serum.    On  microscopical  examination  the  red  globules  appear 

'  Zeitschrift  fiir  rationelle  Medizin,  1855. 

^  Physikalische  und  chemische  Studien  ueber  die  Cholera,     Zurich,  1857. 

^  Charakteristic  der  epid.  Cholera,  etc.     Leipzig,  1850. 

^  Le  Progres  Medical,  February  14,  1885. 


CONDITION  OF  THE  BLOOD.  277 

pale,  diffluent,  but  not  agglutinative,  as  is  the  case  in  the  blood  of  malig- 
nant pustule.  There  is  also  a  great  number  of  globulins  or  microcytes, 
that  is  to  say  of  red  globules  two  or  three  times  smaller  than  normal 
(Hayem).  Owing  to  the  draining  away  of  the  serum  the  relative  propor- 
tion of  red  globules  is  greatly  increased,  so  that  one  cubic  millimetre  con- 
tains over  7,800,000  instead  of  4,000,000  to  4,500,000  which  is  the  normal 
proportion  (Kelsch  and  Renaut).'  The  reaction  of  the  blood  is  usually 
slightly  acid.  When  fresh  blood  taken  from  a  cholera  patient  is  examined 
under  "a  high  power,  there  may  be  seen  in  the  spaces  between  the  globules 
some  extremely  minute  corpuscles,  very  feebly  refractive  and  slight,  often 
elongated  and  narrowed  at  the  center,  and  resembling  micro-organisms. 

Indeed  thev  were  at  first  supposed  to  be  such,  until  further  tests  by 
staining  and  cultures  proved  the  incorrectness  of  the  assumption.  At  the 
request  of  Straus,  Dr.  Malassez  examined  a  number  of  specimens  of  dried 
blood  from  cholera  patients,  and  made  the  following  report  which  had  not 
hitherto  been  published  by  him: 

"  There  are  frequently  found  in  the  blood  of  cholera  patients  very  mi- 
nute bodies  Avhicli  might  readily  be  taken  for  micro-organisms.  When  the 
blood  is  exposed  in  very  thin  layers  on  a  slide  rapidly  dried,  then  hardened 
by  heat  or  chromic  or  osmic  acid,  and  finally  stained  by  gentian  violet 
and  mounted  in  balsam,  these  bodies  are  brightly  stained  and  may  be  seen 
under  various  forms  and  sizes.  Many  resemble  dumb-bells,  or  diplococci, 
the  individual  micrococci  of  which  are  separated  at  some  distance  from 
each  other  and  united  by  a  more  or  less  clearly  visible  filament;  others 
are  like  a  wallet  or  a  biscuit,  as  if  they  were  micro-organisms  in  process 
of  division;  others  again  form  chains  or  filaments  of  varying  length.  In 
brief,  they  might  be  supposed  to  be  different  shapes  of  the  same  micro- 
organism or  different  varieties  of  microbes.  But  they  are  not.  If  a  little 
water  be  added  to  a  specimen  of  the  blood  which  is  simply  dried  but  not 
hardened,  the  red  globules  may  be  seen  to  lose  color  and  finally  to  disap- 
pear, their  hemoglobine  being  dissolved.  And  the  apparent  micro-organ- 
isms comport  themselves  in  the  same  manner;  some  indeed  resist  for  a 
considerable  length  of  time,  but  may  l^e  finally  observed  to  disappear. 
This  disiippearance  of  the  red  globules  and  of  the  minute  bodies  just  de- 
scribed occurs  much  more  rapidly  if  ammoniated  water  or  a  solution  of 
bile  be  used  instead  of  simple  water.  When  treated  in  other  ways  they 
are  also  found  to  act  like  the  red  globules,  receiving  exactly  the  same 
staining  as  the  latter  bodies,  and  differing  in  this  respecct  from  the  glo- 
bulins of  Donne  (known  also  as  the  elementary  corpuscles  of  Zimmer- 
mann,  hematoblasts  of  Hayem,  and  blood  "  plaquettes  "  of  Bizzozero),  and 
from  both  the  protoplasm  and  the  nuclei  of  the  Avliite  corpuscles.  There 
is,  therefore,  reason  to  conclude  that  the  little  bodies  in  question  are  simply 
portions  of  red  globules  drawn  out  and  broken  up,  an  alteration  Avhich  is 
perhaps  due  to  the  extreme  degree  of  concentration  of  the  blood.  The 
members  of  the  French  mission  to  Egypt  reported  having  found  in  the 
blood  of  cholera  patients  very  minute  bodies  which  bore  a  resemblance 
to  the  lactic  ferment.  It  Avas  probably  some  of  this  globular  debris  that 
they  saw,  and  not  the  "  blood  plaquettes"  as  Koch  asserted  in  his  fifth  re- 
port These'  plaquettes"  (hematoblasts  of  Hayem)  bear  no  resemblance 
to  the  bodies  above  described  either  in  form  or  in  size  or  in  their  histo- 
chemical  reactions. " 

'  Le  Proo-res  Medical,  1873,  p.  210. 

2  Fortschritte  der  Medicin,  1884,  No.  5. 


278  ASIATIC  CHOLERA. 

It  may  be  seen  from  this  liow  numerous  are  the  sources  of  error  in 
those  delicate  researches  in  hematolog}^ ;  and  Iiom'  cautious  one  should  be 
in  asserting  the  presence  of  micro-organisms  in  the  blood,  when  the  fact  is 
not  established  positively  by  staining,  and  especially  by  culture  experiments. 
It  is  creditable  to  Straus  to  have  made  so  candid  an  admission  of  his  error, 
after  he  had  himself  claimed  for  these  pseudo-organisms  the  importance 
of  a  new  and  perhaps  vahuible  discovery. 

The  Lungs  are  found  collapsed  and  shrunken.  When  the  thorax  is 
opened  they  appear  to  lie  far  back,  as  if  pressed  against  the  spine.  They 
are  dry  and  generally  pale  in  their  anterior  and  upper  portions.  The  cut 
surface  here  looks  pinkish  or  gray.  Dark  blood  oozes  sloAvly  and  sparingly 
from  the  larger  veins. 

Posteriorly  there  may  be  more  or  less  hypostatic  congestion  and  oedema. 
The  pulmonary  tissue  there  is  friable,  contrasting  in  this  respect  with 
the  toughness  of  the  other  portions  of  the  lung.  The  actual  Aveight  of 
the  organs  may  be  reduced  to  one-half  the  normal  standard. 

In  about  fifty  per  cent,  of  the  cases  examined  by  Sutton,  he  found  the 
lungs  congested  throughout,  and  of  a  dark  red  color. 

Macnamara  reports  out  of  a  whole  number  of  sixty-four  post-mortems, 
of  wliich  he  has  kept  careful  notes,  pulmonary  congestion  thirty-six  times. 
This  was  when  death  had  occurred  in  collapse.  Dr.  Chuckerbuty  '  found 
the  lungs  congested  in  more  than  one-half  of  his  cases. 

In  1854  Baly  and  Gull,^  stated  that  the  hypostatic  engorgement  was, 
in  some  instances,  so  profound  as  to  cause  portions  of  the  lung  to  sink  in 
water. 

On  the  other  hand,  Parkes'  said  that  "  the  most  common  appearances 
in  the  lungs  are  the  collapse  and  the  deficient  crepitation,  arising  from 
the  more  or  less  complete  absence  of  air  and  blood." 

As  regards  the  Larynx,  Trachea,  and  Bronchi,  they  show  little  al- 
teration save  some  pallor  or  lividity  of  their  mucous  surfaces.  At  times, 
however,  exceeding  dryness,  at  others  a  slight  coating  of  frothy  fluid,  and 
again,  patches  of  hyperaemia  and  even  ecchymosis  have  been  observed. 

The  occurrence  of  diphtheritic  and  pseudo-membranous  processes  has 
been  recorded  by  Lebert  and  others.  But  all  such  changes  are  sec- 
ondary and  do  not  belong  to  the  specific  cholera-process.  Moreover,  they 
have  been  only  quite  exceptionally  seen  after  death  during  collapse. 

The  Diploe. — On  opening  the  cranium  the  diploe  presents  an  unu- 
sually red  appearance.  Like  other  osseous  structures  it  is  found  to  be 
abnormally  friable. 

The  IVIeninges  are  seen  to  be  gorged  with  dark  blood:  in  the  sinuses 
of  the  dura  this  is  especially  prominent.  A  few  extravasations  are  found 
here  and  there,  at  the  base  or  over  the  cortex. 

The  arachnoid  often  shows  a  viscid  coating,  and  appears  moist  and 
sticky,  whereas  the  ina  mater  is  generally  dry.  At  times,  however,  it 
appears  oedematous  and  studded  with  patches  of  ecchymosis.  The  ven- 
tricles of  the  brain  are  either  empty  or  only  moderately  distended. 
The  cerebrospinal  fin  id  is  absent  or  diminished,  and,  when  present, 
more  sticky  than  normal.     According  to  Voit  the  encephalic  fluids,  either 


'  Indian  Annals,  1867. 

'-■  Reports  on  Epidemic  Cholera.     Drawn  up  at  the  desire  of  tlie  Cholera  Com- 
mittee of  the  Royal  College  of  Physicians.     London,  1854. 

^  Researches  into  the  Pathology  and  Treatment  of  Asiatic  Cholera.     London, 

1847. 


THE  SPINAL   CORD.  279 

those  belonging  to  meningeal  oedema  or  those  found  in  the  ventricles,  and 
even  the  substance  of  the  brain,  contain  the  largest  relative  accumulation 
of  urea  discoverable  in  the  bodies  of  cholera  patients.  Lehmann  and  Buhl 
have  confirmed  these  observations. 

The  Encephalon  is  drier  than  normal,  especially  the  white  substance. 
Punctate  hyperajmia  is  at  times  observed.  Buhl  also  found  pigmentary 
deposits  in  the  smaller  cerebral  blood-vessels. 

The  Spinal  Cord  shows  the  same  meningeal  hyperaemia  that  exists 
in  the  brain,  and  in  all  other  respects  its  condition  corresponds  to  that  of 
the  encephalon.  Bulil  states  that  he  has  found  the  pneumogastric  nerve 
surrounded  with  a  plexus  of  dilated  blood-vessels,  at  its  j^oint  of  entrance 
into  tlie  chest.  He  also  describes  a  hyperaemic  condition  of  the  ganglia  of 
the  sympathetic.  The  solar  plexus  is  frequently  reddened  through- 
out, and  occasionally  shows  ecchymosis. 

These  appearances  are  not  without  interest,  especially  when  considered 
in  connection  with  Chapman's  peculiar  views  on  the  neurotic  origin  of 
cholera,  fuller  reference  to  which  will  be  found  in  the  chapters  on  etiology. 


230  ASIATIC  CHOLERA. 


CHAPTER  XXXIV. 

MORBID  APPEARANCES  AFTER  DEATH  FOLLOWING  REACTION. 

It  is  but  natural  that  the  post-mortem  appearances  are  found  to  vary 
in  accordance  with  tlie  time  that  has  passed  between  the  first  establishment 
of  reaction  and  the  death  of  the  patient.  Should  the  latter  occur  at  the 
very  incipience  of  reaction,  there  will  be  little  or  no  difference  from  what 
is  seen  in  death  from  collapse.  On  the  other  hand,  after  death  during  or 
following  fully  established  reaction,  some  noteworthy  modifications  of  the 
api^earances  characterizing  collapse  are  constantly  observed. 

In  the  first  place  the  General  Appearance  of  the  Body  is  much 
less  shrunken  indeed  there  may  be  apparent  plumpness.  Eigor  mortis  is 
far  less  pronounced;  it  also  begins  later  and  ends  sooner.  Lividity,  cyanosis, 
and  extensive  cadaveric  blotches  are  less  marked  and  not  infrequently 
absent.  A  post-mortem  rise  of  the  temperature  does  not  take  place.  Mus- 
cular contractions  are  not  observed  after  death.  In  a  Avord,  there  is 
nothing  decidedly  characteristic  about  the  external  appearance  of  a  cholera 
corpse,  when  reaction  was  fully  established  at  the  time  of  death.  The  lips, 
teeth  and  gums  show  a  dark  brown  or  blackish  scum,  and  often  a  thick 
creamy  substance  coats  the  conjunctivae. 

On  opening  the  cadaver  the  connective  tissue  is  found  of  natural  mois- 
ture, the  blood  is  again  more  fluid;  the  muscles,  however,  are  still  dark, 
dry,  and  hard.  According  to  Hamernjk'  an  urinous  odor  often  issues  from 
the  cut  organs,  a  statement  that  has  been  in  turn  denied  and  accepted  by 
other  writers.  At  times  the  buccal  mucous  membrane,  the  palate,  ])liarynx 
and  larynx,  are  found  coated  with  grayish  diphtheritic  membranes,  which 
reveal  underlying  ulcerations.  Generally,  however,  the  upper  respiratory 
passages  present  a  nearly  normal  appearance. 

The  Peritoneum  is  but  rarely  injected  and  covered  with  products  of 
inflammation.  It  has  regained  its  natural  moisture.  A  viscid  scum  is  not 
seen. 

The  Stomach  is  commonly  found  somewhat  contracted,  holding  a 
moderate  amount  of  dirty-looking  fluid.  Its  mucous  membrane  may  be 
injected  and  in  a  catarrhal  condition.  A  croupous  exudation  has  been 
described  by  Pirogoff  ^  and  others,  but  its  joresence  is  quite  exceptional. 
The  "  patches  of  denuded  mucous  membrane,  resembling  in  apppearance 
superficial  ulceration  of  this  organ,"  together  Avith  ''numerous  pus-like 
cells — abortive  epithelial  products,  Avhich  have  been  ineffectually  formed 
to  supply  the  lost  epithelium," — these  appearances  which  are  made  so 
much   of  by   Macnamara,  are   doubtless   largely  the   result  of  cadaveric 

'  Die  Cholera  epideniica.     Prag,  1850. 

2  Anatomie  patholog-ique  du  Cho'era.     St.  Petersburg,  1849. 


THE  ABDOMINAL  ORGANS.  281 

changes,  aithougli  as  will  appear  presently,  diphtheritic  processes  with 
tissue-necrosis  may  occur  in  certain  cases.  But  even  then  they  are  found 
in  the  intestine  rather  than  the  stomach. 

The  Small  Intestine  does  not  contain  rice-water  or  gruel-like  fluid, 
but  gas  is  usually  present  in  some  abundance.  The  internal  surface  is 
coated  M-ith  bilious  mucus.  When  this  is  removed  the  mucous  membrane 
may  be  found  apparently  normal,  or  faintly  injected.  Low  down  in  the 
ileum,  and  quite  generally  in  the  colon,  the  presence  of  fecal  matter  is 
noticed.  But  this  is  not  the  invariable  condition  of  things.  When  death 
has  supervened  after  a  prolonged  typhoid  condition  of  the  patient,  the 
small  intestine  generally  shows  very  decided  anel  advanced  lesions.  Engel' 
and  Hamernjk''  found  extensive  superficial  destruction  of  the  mucosa, 
producing  the  appearance  of  a  network  with  wide  meshes. 

Eeinhardt  and  Leubuscher  describe  appearances  resembling  dysenteric 
intestines,  with  the  usual  hypera?mic  condition,  diphtheritic  membranes, 
necrosis,  and  jagged  ulcers.  (The  latter  in  rare  instances  have  led  to 
perforation  and  peritonitis.)  Bouillaud '  observed  decided  gangrene  in 
only  one  instance  out  of  a  large  number  of  cases. 

The  Large  Intestine. — According  to  Griesinger,  diphtheritic  or  dys- 
enteric ulcerations  are  not  infrequently  encountered  in  the  large  intestine. 
The  solitary  glands  are  commonly  involved  in  this  destructive  process. 
The  same  writer  also  observed  similar  changes  in  the  small  intestine, 
and  he  says  that  Avlien  Peyer's  patches  were  affected,  the  resemblance  to 
typhoid  intestines  Avas  so  complete  as  to  be  misleading.  Yet  these  second- 
ary lesions  are  in  no  way  characteristic  of  cholera.  They  are  mentioned 
here,  however,  because  some  writers  have  laid  much  stress  on  their  oc- 
currence. A  singular  circumstance  connected  with  them  is  their  relative 
frequency  in  some  epidemics,  and  their  almost  entire  absence  in  others. 

The  Mesenteric  Glands  appear  but  slightly  enlarged,  except  in 
those  cases  where  destructive  lesions  in  the  intestine  are  far  advanced, 
Avhen  they  may  be  much  swelled  and  congested. 

The  Spleen  has  regained  its  normal  appearance,  or  is  increased  in 
volume,  hyperaemic,  and  soft.  Its  color  is  quite  generally  darker  than  in 
the  stage  of  collapse.  Infarctions  have  been  repeatedly  observed,  but  must 
nevertheless  be  regarded  us  exceptional.  Splenic  rupture,  as  reported  by 
Niemeyer  and  others,  is  a  rare  accident. 

The  Liver  has  resumed  a  darker  and  more  natural  appearance. 
Tholozan^  asserts  that  he  found  it  congested  in  one-half  of  his  cases.  He 
also  noticed  softening.  This  statement  is  at  variance  with  the  observations 
of  the  majority  of  competent  writers,  who  agree  in  pronouncing  the  liver 
substantially  normal  after  death  during  the  period  of  reaction.  The  gall- 
hJadder  is  only  slightly  or  not  at  all  distended  with  fluid.  At  times  its 
mucous  membrane  is  in  a  catarrhal  state.  Ecchymoses,  diphtheritic  patches, 
ulcerations  and  even  perforation  have  been  described  by  Pirogofl.  °  ]5ut 
they  are  exceptional  occuiTences. 

The  Kidneys, while  showing  no  single  constant  lesion,  are  nevertheless 
always  more  or  less  altered.  At  times  there  is  merely  hypertemic  SAvelling, 
Avith  slight  parenchymatous  degeneration.  Frequently,  fatty  changes  of 
the  tubular  epithelium  are  pronounced  and  widespread,  particularly  so  in 

'  Prager  Vierteljahrschrift,  vol.  iii.,  18.51.  -Op.  citat. 

^  Quoted  by  A.  Mouchet,  Observations  cVacciclents  gangreneux,  chez  es  chol- 
eriques,  in  Archives  generales,  1867. 

■*  Op.  citat.  5  Op.  citat. 


282  ASIATIC  CHOLERA. 

the  cortical  substance.  Many  tubules  are  seen  to  be  filled  with  casts  or 
epithelial  debris. 

In  a  considerable  proportion  of  cases,  the  changes  are  those  of  acute  in- 
fectious nephritis,  with  an  unmistakable  resemblance  to  the  scarlet-fever 
kidney.  This  circumst^mce  is  in  agreement  with  the  clinical  fact  that 
cholera  convalescents  are  but  rarely  known  to  develop  chronic  albuminuria. 
Still  Hamernjk  and  others  have  reported  a  few  cases,  illustrating  the 
possibility  of  such  an  event. 

The  descriptions  of  Leubuscher,  Reinhardt,  Virchow,  Drasche,  and 
indeed  most  of  the  earlier  writers  on  cholera,  are  inadequate  as  regards 
he  pathological  histologv  of  these  interesting  renal  lesions.  And  Eich- 
horst,^  writing  in  1S80,  publishes  a  very  meager  account  of  them. 
Griesinger,*  Laveran^  and  especially  Lebert*  give  more  satisfactory 
descriptions. 

But  it  is  not  necessary  to  reproduce  the  views  of  these  various  writers 
here,  in  order  to  point  out  wherein  their  opinions  differ  and  in  what  re- 
spects there  is  substantial  agreement  among  them.  Quite  recently,  how- 
ever, Straus'  has  made  careful  and  elaborate  investigations  regarding  the 
renal  alterations  of  cholera.  The  great  interest  and  importance  of  the  sub- 
ject warrants  our  presenting  a  summary  of  his  researches. 

In  order  not  to  interrupt  the  continuity  of  his  descriptions,  it  has  been 
thought  advisable  to  consider  the  renal  changes  found  by  him  after  col- 
lapse, together  with  those  of  reaction,  that  alone  properly  belonging  here. 

Straus  did  not  find  the  increase  in  the  size  of  the  kidneys  of  those  dy- 
ing during  algid  collapse  or  shortly  after,  which  several  authors  have  de- 
scribed. Like  Bartels,  he  generally  saw  a  diminution  of  volume.  The 
capsule  was  not  adherent,  except  Avhen  there  was  antecedent  renal  disease. 
On  longitudinal  section  he  finds  the  cut  surface  moist,  the  cortical  sub- 
stance of  a  dull  grayish  red  color,  Avith  here  and  there  points  showing  con- 
gestion and  others  of  a  yellowish  brown  color.  The  glomeruli  are  readily 
visible  to  the  naked  eye,  prominent  and  congested,  with  the  interlobular 
vessels  presenting  as  sunken  lines.  The  medullary  rays  of  the  cortical  sub- 
stance present  a  dull  grayish  color,  contrasting  with  the  deeper  tint  of  the 
pyramids.  The  vascular  arches  of  the  intermediate  substance  are  strongly 
congested.  Pressure  made  with  the  back  of  the  scalpel  upon  one  of  the 
papilla?  causes  an  exudation  of  a  suspicious  looking  fluid  resembling  pus. 
The  mucous  membrane  of  the  pelvis  is  sometimes  pale  and  sometimes 
strongly  congested,  and  of  a  bluish  or  violet  color. 

Examined  under  the  microscope,  the  epithelium  of  the  convoluted 
tubules  is  seen  to  be  profoundly  altered  even  in  very  acute  cases  in  which 
death  has  occurred  in  from  twenty-four  to  thirty-six  hours  after  the  com- 
mencement of  the  disease.  The  cell  markings  are  effaced  and  Heidenhain's 
striation  is  not  present.  The  protoplasmic  substance  is  swollen  and  contains 
irregularly  shaped  granules  of  varying  size,  refractive  to  light,  and  colored 
brown  by  osmic  acid,  the  cloudy  swelling  of  Virchow.  In  consequence  of  the 
cellular  tumefaction, the  lumen  of  the  secretory  tubules  is  almost  completely 
effaced,  while  their  diameter  is  greatly  increased.     The  free  border  of  the 

'  Article  Cholera,  in  Eulenburg's  Real-Encyclopadie. 

-  Article  Infections-Krankheiten  in  Virchow's  Handbuch  der  speciellen  Patho- 
logie  und  Tlierapie.     Erlangen,  1864. 

^  Dictionnaire  encyclopedique  des  sciences  medicales.    Pains,  1874. 
•*  Article  on  cholera  in  Ziemssen's  Cyclopjedia.     New  York,  1874. 
'  Le  Prog-res  Medical,  January  10  and  February  14,  1885. 


THE  KIDNEYS.  28 o 

secreting  cells  is  uneven  and  irregularly  torn,  as  if  it  had  been  nibbled. 
When  the  disease  has  been  of  somewhat  longer  duration  (from  one  to  three 
days),  this  ragged  appearance  of  the  border  is  more  marked,  and  the  proto- 
phism  is  reduced  to  the  condition  of  an  irregularly  granular  substance.  It  is 
only  in  exceptional  cases  that  the  little  colloid  spheres  described  by  Cornil 
in  acute  or  subacute  nephritis  and  in  poisoning  by  cantharides  can  be 
seen  in  osmic  acid  preparations. 

Straus  did  not  find  fatty  degeneration  of  the  epithelium  of  the  con- 
voluted tubules  as  described  by  Reinhardt,  L.  ^Nleyer,  Bartels,  and  others. 
The  granular  dust  to  which  the  cellular  protoplasm  is  reduced  seems  to 
be  in"  part,  at  least,  of  hematic  nature,  as  is  evidenced  by  the  reddish  color 
which  it  assumes  with  eocene,  and  the  greenish  brown  hue  which  picro- 
carminate  of  ammonia  causes  it  to  take.  A  similar  hematic  infiltration  of 
the  kidney  has  been  seen  in  various  infectious  diseases,  by  Kelsch  and 
Kiener  in"  malaria,  by  Renaut  in  typhoid  fever,  and  by  Brault  in  diph- 
theria. 

Wliile  these  changes  have  been  taking  place  in  the  protoplasmic  substance 
the  nucleus  still  remains  visible.  But  it  is  shifted  toward  the  basal  portion 
of  the  cell  and,  while  retaining  its  circular  form,  appears  swollen  and  as 
if  pitted  with  little  holes.  Those  coloring  agents  which  have  an  affinity 
for  the  nuclei,  stain  it  indeed,  but  less  deeply  than  normal;  the  aniline 
colors  stain  it  quite  distinctly,  while  Ranvier's  picro-carminate  of  ammonia 
does  so  but  feebly. 

In  certain  parts,  where  the  lesions  are  most  pronounced,  some  of  the 
secreting  cells  are  seen  to  be  converted  into  a  granular  mass  without 
any  apparent  nuclei,  but  the  portions  in  Avhicli  such  changes  are 
visible  are  isolated  and  involve  only  a  small  number  of  the  tubules.  These 
nuclear  lesions  are  insisted  upon  by  the  writer  as  of  no  slight  importance. 
In  the  straight  tubules  of  the  medullary  portion  these  alterations  are  much 
less  marked;  the  cylindrical  cells  present  an  even  contour,  with  normal 
nuclei  which  receive  a  bright  staining.  One  remarkable  fact  is  that  neither 
in  the  convoluted  nor  in  the  straight  tubules  are  any  hyaline,  or  colloid, 
casts  met  with. 

The  capillaries  between  the  tubules  are  seen  to  be  enormously  dis- 
tended, and  in  certain  places,  though  very  rarely,  red  blood-corpuscles  are 
seen  within  the  lumen  of  the  convoluted  tubes.  The  interlobular  spaces 
are  also  frequently  distended  by  an  amorphous  or  very  finely  granular 
mass,  colored  a  pale  gray  by  osmic  acid,  collected  in  sorts  of  splashes. 
This  is  an  albuminous  exudation  between  the  tubules  due  to  an  acute 
oedema  of  the  cholera  kidney,  and  analogous  to  the  acute  inflammatory 
oedema  described  by  Renaut  as  occurring  in  certain  forms  of  infectious  ne- 
phritis. But  Straus  insists  that  in  cholera  there  is  not,  properly  speaking, 
an  inflammatory  oedema,  since  the  interstitial  albuminous  exudation  never 
contains  leucocytes.  There  is  not,  he  claims,  in  the  cholera  kidney  any 
infiltration  of  the  connective  tissue  interstices  with  leucocytes.  This  was 
also  asserted  by  Kelsch  in  1874. 

In  the  ^Nlalpighian  bodies  there  is  a  partia^  desquamation  of  the  endothe- 
lial lining  of  the  capsule,  and  where  it  remains  in  place  it  is  visibly  altered 
and  the  cell  presents  a  projecting  nucleus.  The  capillary  tufts  appear 
increased  in  number  and  the  glomerular  capillaries  themselves  are  filled  with 
red  blood-globules.  Within  the  capsule  and  surrounding  the  glomerulus 
there  is  frequently  an  exudation  of  coagulated  albumen,  identical  with  that 
seen  in  the  spaces  between  the  tubules,  and  like  it  also  never  containing 


284  ASIATIC  CHOLERA. 

aiw  leucoc}i;es.  Rarely  the  exudation  contains  some  red  blood-globules. 
In  a  certain  number  of  the  larger  and  medium-sized  tubes  of  the  pyramids 
there  is  a  complete  loss  of  the  epithelium,  as  if  it  had  been  brushed  away; 
and  in  other  tubes  the  lumen  is  filled  up  completely  with  a  homogeneous 
mass,  colored  gray  by  osmic  acid,  which  is  nothing  else  than  coagulated 
albumen.  These  albuminous  molds  fit  closely  against  the  walls  of  the 
tubules,  showing  that  the  epithelium  had  fallen  oif  during  life  and  had 
not  been  torn  away  by  the  manipulations  used  in  preparing  the  specimen. 
In  some  of  the  tubes  the  epithelium  is  still  present  but  is  raised  up  by  an 
albuminous  exudation  between  it  and  the  tube  wall.  In  other  parts  the 
epithelial  lining  is  in  place,  but  the  cells  seem  flattened  and  depressed  to 
the  level  of  the  nucleus,  which  remains  prominent  and  surrounded  by  a 
very  thin  layer  of  protoplasm.  In  sections  made  parallel  with  the  straight 
tubes  the  epithelial  debris  can  be  seen  as  casts,  and  sometimes  in  tlie  larger 
tubes  twisted  into  corkscrew  shapes  by  the  action  of  the  urine  forcing  them 
along.  In  carefully  made  sections  the  straight  vessels  of  the  pyramid  are 
seen  to  be  filled  with  blood,  as  if  artificially  injected.  They  are  grouped 
in  bundles  alternating  with  the  bundles  of  the  urinary  tubules.  Certain 
of  the  latter  are  also  filled  with  red  blood-globules.  This  transudation  of 
blood  which  occurs  so  exceptionally  in  the  convoluted  tubules,  is  very 
common  and  very  marked  in  the  pyramids. 

In  individuals  Avho  have  succumbed  at  a  later  period,  during  the  stage 
of  typhoid  reaction,  the  lesions  are  of  the  same  sort  but  more  pro- 
nounced. The  Malpighian  bodies  have  lost  a  great  part  of  their  endothe- 
lial lining,  and  there  is  frequently  within  the  capsule  a  granular  exudation, 
dotted  with  points  stained  a  deep  black  by  osmic  acid  (fat),  and  containing 
a  certain  number  of  nuclei.  The  alterations  in  the  convoluted  tubules 
are  very  marked;  the  striated  epithelium  is,  in  places,  almost  wholly  de- 
stroyed, and  nothing  is  found  but  the  nuclei  of  the  cells,  more  or  less 
deformed  or  vesicular.  The  lumen  of  the  tubule  is  greatly  dilated  and 
filled  with  granular  and  fatty  detritus,  and  here  and  there  are  great  splashes 
of  fat  colored  an  inky  black  by  osmic  acid.  In  certain  places  the  epithe- 
lium of  the  convoluted  tubules  is  less  altered  and  the  cells  have  preserved 
their  form  indistinctly,  some  of  the  latter  containing  no  nuclei.  The 
straight  tubules  are  also  altered  in  the  manner  before  described,  but  in 
greater  degree. 

A  study  of  these  renal  lesions  described  by  Straus  shows  that  they  may 
be  regarded  as  quite  typical  of  infectious  nei)hritis,  so  called  by  Bouchard. 
Formerly  the  kidney  lesions  found  in  cholera  were  almost  universally 
thought  to  be  inflammatory  in  their  nature.  Eeinhardt  and  Frerichs 
called  it  a  croupous  nephritis,  and  according  to  Virchow  it  was  a  catarrhal 
nephritis  beginning  in  the  calices  and  thence  passing  gradually  upward  to 
the  convoluted  tubules,  and  sometimes  becoming  croupous  by  reason  of  a 
fibrinous  exudation.  Rosenstein,  Lecorche  and  Bartels  are  all  agreed  in 
admitting  the  inflammatory  nature  of  the  process,  and  class  the  funda- 
mental lesion  of  the  kidney  in  cholera  as  one  of  the  forms  of  parenchyma- 
tous nephritis.  L.  Meyer,  however,  regarded  it  as  merely  a  passive  re- 
gressive alteration  in  the  kidney  due  to  venous  stasis.' 

In  a  memoir  published  in  1874,  M.  Kelsch^  advanced  a  different  opinion. 

'Beitrage  zur  Pathologie  des  Cholera-Typhoids.  Virchow's  Archiv,  Bd.  vi., 
p.  471. 

•  Revue  critique  et  anatorao-pathologique  sur  la  maladie  de  Bright.  Archives 
de  Physiologie,  1874,  p.  748. 


THE  KIDNEYS.  285 

He  maintained  that  there  was  neither  a  catarrhal  inflammation,  nor  a 
croupous  process,  nor  even  a  parenchymatous  nephritis.  The  epithelial 
alterations  were  purely  of  a  regressive  nature  and  due  clearly  to  arterial 
ischsemia.  Indeed,  he  said,  the  retardation  of  the  circulation  was 
so  marked  that  the  relation  of  cause  to  effect  (/.e.,  the  isch^emia  to  the 
death  of  the  epithelium),  was  easily  established  and  unmistakable.  He 
agreed  with  L.  Meyer  in  believing  the  renal  alterations  to  be  of  a  regressive 
nature,  but  he  differed  from  him  in  assuming  the  cause  to  be  arterial  ischae- 
mia  rather  than  venous  stasis.  The  researches  of  Straus  are  confirmatory 
of  Kelsch's  views. 

But  before  examining  these  it  is  necessary  to  say  a  few  words  concerning 
the  experiments  of  Weigert '  upon  what  is  known  as  coagulation-necrosis. 
This  process  is  defined  as  a  special  alteration  of  the  cellular  elements,  con- 
sisting, on  the  one  hand,  of  a  sort  of  fibrinous  transformation  of  a  coagula- 
tion of  the  protoplasmic  substance,  and  on  the  other,  of  a  rapid  disappear- 
ance of  the  cell  nucleus,  which  becomes  incapable  of  being  stained  by  those 
very  coloring  materials  which  possess  a  special  affinity  for  nuclei. 

Tills  necrosis  with  coagulation  may  be  determined  by  various  causes,  of  a 
zymotic  nature  (in  croup,  for  example),  or  of  a  physico-chemical  one,  or  by 
vascular  troubles,  and  especially  by  arterial  ischasmia.  As  regards  the  last 
mentioned  condition,  AVeigert  has  shown  that  when  it  is  complete  and  perma- 
nent, it  produces  necrosis,  pure  and  simple,  with  its  Avell-known  histological 
features.  But  in  order  that  this  special  form,  called  coagulation-necrosis, 
should  be  produced,  it  is  necessary  that  the  anatomical  elements  after  having 
been  touched  by  death,  should  continue  to  be  bathed  and  traversed  by  a  cer- 
tain amount  of  lymphatic  fluid.  In  other  words,  it  is  necessary  that  the 
ischgemia  should  be  only  temporary,  and  should  be  followed  by  the  reestab- 
lishment  of  a  nearly  normal  circulation.  Coagulation-necrosis  is  thus  a 
result  of  transitory  disturl^ances  of  the  arterial  circulation. 

As  regards  the  pathological  anatomy  of  the  kidney  in  particular,  the 
researches  of  Litten"  throw  considerable  light  upon  coagulation-necrosis. 
He  placed  a  ligature  upon  the  renal  artery  in  rabbits,  removing  it  after  two 
or  three  hours;  then  at  the  end  of  thirty-six  to  forty-eight  hours  the  animals 
Avere  killed,  and  the  kidneys  Avere  found  to  be  the  seat  of  the  lesions  just  de- 
scribed as  those  of  coagulation-necrosis.  Noav  the  mechanical  conditions  in 
respect  to  the  renal  circulation  in  cholera  are  very  similar  to  those  induced 
artificially  by  Litten.  During  the  algid  stage  the  arterial  pressure  is  reduced 
to  a  minimum,  and  the  kidneys  feel  the  effects  of  this  diminished  pressure 
as  Avell  as  the  other  organs.  But  later,  during  the  period  of  reaction  or 
of  incomplete  attempts  toward  reaction,  the  renal  circulation  is  reestab- 
lished, as  is  evidenced  by  a  renewal  of  urinary  secretion.  Thus,  theo- 
retically at  least,  the  kidney  in  cholera  is  in  a  condition  of  temjDorary 
arterial  ischasmia  followed  by  a  return  of  the  circulation.  Cohnheim  speaks 
of  this  resemblance  to  the  circulatory  disturbances  Avhicli  experimentally 
produce  coagulation-necrosis,  and  he  suggests  that  it  may  be  the  cause  of  a 
like  change  in  cholera.  But  he  was  unable  to  confirm  this  suggestion,  owing 
to  the  lack  of  pathological  material  in  the  absence  of  a  cholera  epidemic. 

Straus  made  his  examinations  of  the  renal  lesions  with  this  idea  in  mind, 
and  he  states  that,  while  the  lesions  are  of  a  regressive  nature,  necrobiotic 

'  Ueber  die  pathologischen  Gerinnungsvorgange.  Virchow's  Archiv,  1880, 
p.  103. 

'^  Untersuchungen  iiber  den  hemorrhag.  Infarct.  Zeitschrift  fiir  Klin.  Med,, 
1879,  p.  131,  and  Virchow's  Archiv,  1881,  p.  508. 


286  ASIATIC  CHOLERA. 

in  their  essence,  approaching  in  several  particulars  to  what  is  known  as 
coagulation-necrosis,  they  nevertheless  do  not  realize  a  perfect  type  of  this 
condition.  The  protoplasm  of  the  epithelial  cells  does,  indeed,  undergo  a 
proteinous  degeneration,  but  it  is  not,  he  says,  converted  into  anything 
resembling  fibrous  tissue,  such  as  occurs  in  white  infarction  of  the  kidney, 
induced  experimentally.  And  on  the  other  hand,  the  cell  nuclei  are  still 
capable  of  being  stained,  although  feebly,  by  coloring  materials,  whi  .h  is  not 
the  case  in  typical  coagulation-necrosis.  Thus,  he  says,  the  process  ap- 
proaches coagulation-necrosis  but  does  not  fully  realize  its  true  type,  and 
it  would  be  forcing  facts  to  conform  to  theories  to  maintain  the  absolute 
identity  of  the  two  conditions.  But,  the  writer  adds,  it  is  certainly  estab- 
lished that  the  renal  lesion  in  cholera  is  of  a  manifestly  passive,  necrotic 
nature,  and  that  there  is  no  infectious  disease  Avliich  determines  mortifi- 
cation and  desquamation  of  the  renal  epithelium  Avith  such  intensity,  and 
especially  with  such  rapidity,  as  does  cholera. 

As  to  the  part  played  by  temporary  arterial  ischemia  in  the  production 
of  these  lesions,  M.  Straus  ventures  no  definite  opinion,  and  says  that 
though  the  theory  is  a  very  seductive  one,  it  must  be  acceptedwith  caution. 
For  the  renal  circulation  in  the  collapse  of  cholera  is  never  so  completely 
abolished  as  it  is  in  arterial  embolism,  or  by  the  application  of  a  ligature  to 
the  renal  artery.  This  partial  isch^emia  may  assist  in  the  production  of 
these  alterations,  but  the  essential  cause,  he  thinks,  is  to  be  found  in 
blood  changes,  of  whatever  kind  they  may  be.  For  the  kidney  lesions 
of  cholera  do  not  differ  materially  in  their  nature  from  those  occurring 
in  the  course  of  other  infectious  diseases,  in  which  blood  changes  are 
present  but  in  which  there  is  no  question  of  arterial  ischemia. 

In  this  connection  we  may  also  allude  to  the  fact  that  MM.  Ceci  and 
Klebs  have  recently  published  a  note  concerning  their  investigations  on 
cholera  made  at  Genoa,'  in  which  they  describe  renal  lesions  very  like 
those  found  by  Straus.  They  believe,  however,  that  the  alteration  of  the 
epithelial  cells  is  actually  a  coagulation-necrosis,  and  they  state  that  the 
cell  iniclei  were  either  not  stained  at  all,  or  only  very  slightly,  by  gentian 
violet.  Straus,  it  Avill  be  remembered,  Avas  never  able  to  discover  so  pro- 
found a  lesion  of  the  nuclei  as  this  implies. 

The  renal  pelvis,  cahjces  and  vreters  are  generally  found  congested, 
with  the  mucous  memlDrane  in  a  condition  of  catarrhal  swelling.  A 
creamy  coating,  composed  of  pus  and  desquamated  epithelium,  is  a  fre- 
quent occurrence. 

The  Bladder  may  be  found  empt}^  as  in  death  during  the  stage  of 
collapse.  More  frequently,  however,  it  contains  some  light-colored,  turbid 
urine,  with  an  abundance  of  flocculi,  composed  of  mucus,  pus  and  detached 
epithelial  cells.  At  times  the  moderate  hyperiemic  swelling  of  the  mucous 
membrane,  which  is  rarely  absent,  may  be  observed  to  have  become  inten- 
sified, and  dirty  patches,  resembling  diphtheritic  membrane,  are  then 
found  scattered  over  its  surface. 

The  Female  Genital  Organs  are  often  found  normal.  In  several 
epidemics,  however,  marked  congestion  of  the  uterine  mucous  membrane 
was  the  rule.  This  condition  was  seen  as  well  in  women  after  the  meno- 
pause as  in  the  younger  ones.  Bloody  extravasations  and  diphtheritic 
coatings  were,  however,  oidy  rarely  seen. 

The  ovaries  and  vagina,  as  a  rule,  participate  in  the  hypersemic  condition 

'  Semaine  Medicale,  No.  49,  1884. 


THE  HEART  AND  LUNGS.  287 

of  tlie  uterus.     And  when  that  organ  is  normal  they,  too,  have  a  healthy 
appearance 

The  Heart. — The  pericardium  is  found  moist;  the  sac  often  contains 
some  iluid,  though  never  much.  Subpericardial  ecchvmosis  is  quite  rare. 
The  heart  still  shows  more  blood  on  the  right  than  the  left  side.  The  fluidity 
of  the  blood  has  generally  returned,  and  its  dark  color  has  almost  disap- 
peared. In  exceptional  cases  it  remains  rather  thickish.  Fibrinous  clots 
are  often  found  deposited  upon  the  valves  and  may  be  entangled  in  the 
tendinous  cords  and  trabecula?.  Endocai'ditis  is  rare.  Briquet  and  ^lignot 
in  meeting  with  several  cases  have  certainly  had  an  exceptional  experience. 
A  supposed  endarteritis  has  been  several  times  described,  but  its  presence 
seems  to  have  been  inferred  from  clinical  evidence  rather  than  post-mortem 
findings.  Laveran  records  some  French  observations  where  the  occur- 
rence of  gangrene  led  to  the  assumption  of  existing  endarteritis.  Still, 
it  is  true  that,  in  one  instance,  an  autopsy  fully  confirmed  the  diagnosis  of 
such  a  condition.  This  case  is  described  by  Dr.  Laugier, '  and  concerned 
a  man  who,  during  the  stage  of  reaction,  developed  gangrene  of  the  foot.  A 
firmly  adherent  clot  was  found  post-mortem  in  the  peroneal  artery,  and 
the  presence  of  endarteritis  could  not  be  questioned.  According  to  Laveran, 
clioUra  gangrene  could  result  either  from  embolism,  as  just  described,  or 
it  may  be  brought  about  by  the  general  condition  of  the  patient.  The 
finding  of  heart-clots  of  presumably  ante-mortem  formation  lends  consid- 
erable probability  to  the  former  assumption.  But  as  to  the  latter,  it  ap- 
pears doubtful  whethert  he  temporary  glycosuria  (Gubler)  now  and  then 
observed  during  reaction  has  anything  to  do  with  the  formation  of  the  mul- 
tiple gangrenous  phlegmons  observed  by  a  number  of  writers.  This  view 
must  be  maintained  in  spite  of  Mouchet's  observations,  Avliich  no  doubt 
show  a  marked  similarity  between  diabetic  and  cholerais  gangrene.  But 
this  resemblance  only  demonstrates  that  a  vitiated  constitution  favors  tissue- 
necrosis,  which  is  an  essentially  local  process. 

The  muscular  substance  of  the  heart  looks  paler,  and  it  has  a  more 
flabby  and  softer  feel  than  in  death  from  collapse.  But  fatty  degenera- 
tion of  the  fibers  has  not  been  discovered,  although  repeatedly  searched 
for. 

The  Lungs. — Collapse  of  the  lungs,  which,  it  will  be  remembered, 
is  singularly  well-marked  in  death  during  the  algid  stage,  is  not  seen  after 
reaction.  Even  the  upper  and  anterior  portions  of  these  organs  contain 
plenty  of  thinly  fluid  blood.  Often,  indeed,  there  is  a  general  pulmonary 
hypertemia;  hypostatic  congestion  is,  as  a  rule,  quite  pronounced; 
cjedema  is  rarely  absent ;  hemorrhagic  infarctions  happen  rather  frequently. 

Lobular  infiltrations,  of  a  catarrhal  kind,  greatly  exceed  in  point  of  fre- 
quency the  lobar  consolidations.  Xevertheless,  the  latter  variety  of  inflam- 
mation has  been  repeatedly  observed.  The  dead-house  shows  that  the 
lobular  pneumonia  and  capillary  bronchitis  of  cholera  does  not  readily  lead 
to  resolution.  Eeinhardt  and  Leubuscher  describe  the  presence  of  cavi- 
ties filled  with  a  purulent  fluid. 

Pulmonary  gangrene  is  occasionally  found,  but  it  is  by  no  means  as 
frequent  a  result  as  one  would  expect  to  encounter  from  a  priori  consider- 
ations. In  five  hundred  and  forty  cases  of  cholera  observed  in  the  service 
of  Horteloup  it  occurred  only  a  single  time. 

The  condition  of  the  j^feura  is  like  that  of  the  other  serous  membranes. 

'  De  la  g-angreue  dans  la  cholera.     Gazette  des  hopitaux,  1866. 
-  Des  atlectioiis  seeoudaires  du  cholera.     These  de  Paris,  1867 


288  ASIATIC  CHOLERA. 

Siibpleural  eccliymoses  occur,  but  they  are  exceptional  findings.  Evi- 
dence of  localized  pleuritic  effusion  is  not  infrequently  obtained.  At 
times  purulent  pseudo-membranes  may  be  seen  coating  the  visceral  and 
parietal  layers  of  the  pleura. 

The  Brain  and  its  Membranes. — An  examination  of  the  meninges 
of  the  brain  shows  a  normal  dura,  serous  effusion  with  more  or  less  conges- 
tion of  the  pia,  and  generally  a  watery  transudation  into  the  sac  of  the  arach- 
noid. It  may  be  mentioned  in  this  connection,  that  there  is  little  or  no 
hypersmia  of  the  diploe,  a  sharp  contrast  to  what  is  the  rule  in  death 
during  collapse.  Meningeal  eccliymosis  is  not  infrequetit.  The  dural 
sinuses  are  not  clogged  with  blood.  The  pia  sometimes  adheres  in  circum- 
scribed areas  to  the  substance  of  the  brain.  Products  of  inflammatory 
action  are  but  rarely  found  deposited  upon  the  membranes.  Briquet  and 
Mignot  only  saAV  such  a  condition  once  in  thirty-seven  autopsical  examina- 
tions. 

The  encephalon  is  normally  moist  or  shows  an  excessive  serous  imbibi- 
tion. There  is  an  increased  amount  of  cerebro-spinal  fluid.  The  latter 
contains,  according  to  Voit,  a  considerable  proportion  of  urea.  This  also 
applies  to  the  substance  of  the  brain,  the  amount  of  urea  being  greatly 
in  excess  of  that  found  in  collapse.  Schmidt  discovered  decomposed  urea 
(carbonate  of  ammonia)  in  the  cerebro-spinal  fluid;  Lehmann,  however, 
like  Voit,  reports  only  the  presence  of  urea.  It  is  quite  notcAVorthy  that 
both  the  Avhite  and  gray  matter  are  always  found  congested  Avhenever 
cerebral  symptoms  were  well-marked  during  the  life-time  of  the  patient. 
Bloody  suffusions  and  small  hemorrhages  are  also  recorded.  Apoplexy 
has  been  observed  by  Lev}^'  Mouchet,  Tholozan,  and  others. 

Softening  of  the  brain  is  rare.  Potain''  has  recorded  two  instances 
of  this  kind.  In  both  cases  the  patients  had  convulsive  symptoms.  Decoi'e  ' 
found  minute  ecchymoses  on  the  floor  of  the  fourth  ventricle  in  the  case 
of  a  woman,  who  developed  tetanus  in  the  course  of  an  attack  of  cholera. 
While  it  is  usual  to  find  the  cerebral  lesions  in  correspondence  with  the 
brain  symptoms  during  life,  cases  have  been  observed  ^  where  ajiparently 
meningitic  phenomena  occurred  without  the  discovery  of  the  slightest  ence- 
phalic change.  Schneller  ^  describes  marked  hyperiemia  of  the  retina  as 
a  common  condition  in  cholera.  He  says  that  the  retina  closely  hugs  the 
choroid,  except  where  slight  hemorrhages  have  produced  a  separation  of 
the  two  membranes.     Other  observers  failed  to  discover  retinal  congestion. 

The  Spinal  Cord  and  its  Meninges  require  no  separate  descrip- 
tion, as  their  post-mortem  appearance  corresponds  in  all  respects  with 
the  morbid  changes  observed  in  the  brain  and  its  coverings,  as  described 
as  above. 

Conclusion. — From  the  descriptions  given  in  the  foregoing,  it 
appears  that  the  microscopical  examination  of  the  various  organs  after 
death  from  cholera  has  not  thrown  very  much  light  on  the  nature 
of  the  disease,  unless  we  make  exception  in  favor  of  some  of  the  most 
recent  researches.  In  a  general  Avay  it  may  ]je  said  that  there  occur  in 
cholera  widespread  parenchymatous  clianges  varying  considerably  in  the 
degree  of  their  intensity. 

'  Gazette  des  hopitaux,  1848. 

'^  Bulletin  et  mem.  de  la  Soc.  med.  des  hopitaux  de  Paris,  1867. 

3  These  de  Paris,  1866. 

^  Einig-es  ueber  die  Cliolei-a  Epidemie,  etc.     Deutsche  Klinik.     1856. 

^  Etats  mening-itiques  dans  le  cholera.     Gazette  des  hopitaux.     March,  1866. 


EDITOR'S  CONCLUSIONS.  289 

Cloudy  swelling,  coagulation-necrosis,  granulo-fatty  degeneration, 
hemorrhagic  and  necrotic  disintegration  of  cells  and  tissues  are  the  leading 
types  of  the  pathological  changes  encountered.  In  all  cases,  circulatory 
disturbances — an  alternation  between  anemia  and  congestion, then  stasis,  ex- 
travasation, and  the  like — precede  or  accompany  the  tissue-changes  men- 
tioned above.  Such  processes  being  frequently  observed  in  many  other 
diseases  fail  to  characterize  cholera  as  the  affection  ^ui  generis  which  it 
undoubtedly  is.  To  explain  satisfactorily  its  true  nature  we  are,  therefore, 
compelled  to  look  beyond  the  tissue  changes  discoverable  after  death. 
But  if  we  invoke  the  aid  of  specific  micro-organisms  of  virulent  toxsemic 
properties,  the  parenchymatous  degenerations  just  mentioned  acquire  a 
new  significance.  They  may  then  be  interpreted  as  specific  infectious 
processes,  that  are  anatomically  indistinguishable  from  similar  metamor- 
phoses occurring  in  other  diseases.  Hence,  far  from  antagonizing  the 
doctrine  of  Koch,  the  pathological  histology  of  cholera  furnishes  a  strong 
additional  argument  in  favor  of  its  truth.  The  rapidity  with  which  the 
organs  and  tissues  of  the  body  become  morbidly  altered  is  more  easily  un- 
derstood by  assuming  the  parasitic  origin  of  cholera  in  Koch's  sense  than 
by  any  theory  yet  announced. 
19 


PART  FIFTH. 


DIAGNOSIS,   DIFFERENTIAL   DIAGNOSIS 
AND  PROGNOSIS  OF  CHOLERA. 


THE  METHODS  OF  BACTERIOSCOPY  A^D  THE 
PREPARATION  OF  PURE  CULTURES. 


BY 

EDMUND  C.  WENDT,  M.D., 

OP  NEW  YORK. 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.  293 


CHAPTER    XXXV. 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS. 

During  the  prevalence  of  an  epidemic  of  cholera,  the  physician  will 
experience  no  difficulty  in  recognizing  a  decided  attack  of  the  disease. 
At  such  a  time  it  is  only  the  atypical  cases,  and  perhaps  the  earlier  period 
of  typical  ones,  that  may  puzzle  him.  Where  a  doubt  exists,  prudence 
suggests  that  the  benefit  of  the  same  be  given  to  the  patient.  In  other 
words,  suspicious  cases  have  been,  and  should  be  classed  and  treated  as 
instances  of  the  real  disease.  But  before  Asiatic  cholera  has  been  recog- 
nized to  exist  in  a  given  locality,  there  will  be  much  more  difficulty  in 
pronouncing  positive  judgment  upon  a  given  case.  And  yet  it  is  precisely 
at  such  a  time,  and  more  particularly  during  that  jieriod  of  anxious  uncer- 
tainty and  apprehensiveness,  when  the  disease  is  still  spreading  in  countries 
or  states  in  active  commercial  and  personal  intercourse  with  the  one  not 
yet  invaded,  it  is  at  such  a  period  that  the  gravest  responsibility  rests  with 
him  Avho  is  called  upon  to  decide  the  true  nature  of  a  suspicious  case. 

For  errors  in  diagnosis  may  signify  little  after  the  first  ravages  of  the 
disease  have  already  spread  dismay,  consternation  and  panic  among  the 
ignorant  populace.  But  an  error  in  diagnosis  may  signify  everything 
when  the  disease  is  not  actually  with  us. 

Everybody  at  all  familiar  with  modern  metropolitan  life,  must  know 
how  readily  false  rumors  may  spread  and  grow,  creating  mischievous 
panics  in  their  course.  Especially  among  the  illiterate  foreigners  that  are 
herded  together  in  various  quarters  of  our  large  towns,  much  needless 
havoc  could  be  created  by  premature  or  unfounded  reports  announcing  the 
occurrence  of  cholera.  Concealment  or  suppression  of  the  truth,  where 
intelligent  persons  or  communities  are  concerned,  is  never  advisable.  It 
is  to  be  supposed  that  through  the  daily  j^ress  and  other  channels  of  infor- 
mation the  possibility  of  a  cholera  visitation  is  duly  recognized  long  before 
its  actual  appearance.  Hence  the  educated  portion  of  the  public  will  be 
less  apt  to  start  a  panic  from  the  senseless  exaggeration  of  perils  that,  faced 
with  calm  judgment,  may  be  kept  in  check. 

But  it  is  ditt'erent  with  the  ignorant,  prejudiced,  or  even  half-instructed. 
To  them  the  mere  mention  of  the  word  "  cholera"  suggests  all  that  is  ter- 
rible, mysterious,  and  deadly  in  a  wicked  and  hateful  pestilence.  And 
among  the  bigoted  there  are  those  Avho,  even  to-day,  invest  the  disease 
with  all  the  fearful  personality  and  sinister  power  that  Ijelongs  to  the  devil 
they  believe  in.  If,  therefore,  it  be  considered  ex])edient  to  call  all  sus- 
picious cases,  occurring  during  an  epidemic  outbreak,  instance  of  genuine 
cholera,  it  certainly  seems  ''good  policy,"  before  that  time,  to  exercise 
extreme  caution  about  the  positive  expression  of  opinion.  So  that  even 
when  our  own  judgment  regarding  a  given  case  is  quite  made  up,  it  may 


294  ASIATIC  CHOLERA. 

be  well  to  avoid  its  premature  announcement.  Under  such  circumstances, 
Avherever  practicable,  a  consultation  Avitli  others  should  be  had.  But  even 
during  the  period  of  uncertaint}^,  the  necessary  precautionary  measures 
may  be  instituted.  And  this  can  be  done  in  so  quiet  a  way  that  needless 
fear  and  excitement  Avill  be  wholly  avoided. 

Regarding  the  actual  recognition  of  Asiatic  cholera,  we  must  remem- 
ber that  characteristic  phenomena  of  an  attack  do  not  belong  to  its  early 
period.  At  that  time  certain  symptoms  may  be  construed  as  premonitory 
signs,  but  since  recovery  may  occur  at  any  moment  it  would  be  wrong  to 
announce  a  positive  diagnosis.  These  early  signs  consist  mainly  in  a  more 
or  less  watery  diarrhaa,  tinnitus  aurium,  associated  perhaps  Avith  nervous 
trembling  or  even  vertigo,  mild  colicky  pains,  more  or  less  nausea,  a  small 
and  rapid  pulse,  and  a  tendency  to  peripheral  coldness.  The  cool  and 
pale  tongue,  some  burning  sensation  at  the  epigastrium,  perhaps  a  little 
griping,  complete  a  picture  Avhich  is  certainly  not  suggestive  of  the  gravity 
the  case  may  assume  a  little  later  on.  In  all  probability  those  cases  that 
end  in  rapid  recovery  actually  rei^resent  very  slight  degrees  of  choleraic 
infection.  But  unless  the  modern  methods  of  Imcterial  examination  are 
accepted  as  giving  absolutely  reliable  results,  we  have  no  means  of  reaching- 
a  positive  diagnosis  of  cholera  in  this  the  incipient  stage.  If  during  the 
prevalence  of  an  epidemic  such  cases  are  generally  set  down  as  instances- 
of  the  disease,  Ave  have,  nevertheless,  no  right  to  say  that  they  have  been 
proved  to  be  such.  Ea'cu  if  subsequent  events  bear  oiit  the  truth  of  our 
assumption,  its  arbitrary  nature  must  be  apparent  to  all  before  the  sequel 
has  furnished  the  needed  demonstration. 

Precisely  similar  symptoms,  during  the  absence  of  an  epidemic,  Avould 
invariably  be  assumed  to  merely  indicate  the  presence  of  simple  cholera. 

It  seems  to  the  editor  that  in  this  direction  the  chief  practical  signifi- 
cance of  Koch's  researches  is  to  be  found.  If  modern  bacterioseopy  Avill 
give  us  the  means  of  deciding  positively,  in  a  given  case.  Avhether  Ave  are 
dealing  Avith  n  non-contagious  disease  like  cholera  morbus,  or  Avith  a  malig- 
nant affection  like  the  Asiatic  variety,  Ave  should  eagerly  Avelcome  this 
ncAV  method  of  conducting  scientific  inquiries. 

In  the  chapters  on  Etiology  the  details  of  Koch's  researches  Avill  be 
found,  together  Avith  the  reasons  for  and  against  the  acceptance  of  his 
doctrine  concerning  the  causation  of  cholera.  But  it  has  been  deemed 
expedient  to  devote  a  separate  chapter  to  the  methods  of  bacterioseopy, 
especially  as  applied  to  diagnosis,  and  this  Avill  be  found  at  the  end  of 
the  present  part  of  the  volume.  Disregarding  for  the  moment  the  modern 
bacterial  aspect  of  the  subject,  let  us  next  turn  our  attention  to  the  stage 
of  fully  developed  activity  of  an  attack  of  cholera.  Here  Ave  are  confronted 
with  difficulties  that  seem  slight  as  compared  Avitli  those  previously  encoun- 
tered. They  may  nevertheless  constitute  an  effectual  barrier  to  positive 
differential  recognition. 

!Many  Avriters  draAv  so  viA'id  a  picture  of  a  rarely-missing  group  of  char- 
acteristic symptoms,  tlmt  the  veriest  tyro  should  at  a  glance  be  able  to  say : 
"  This  is  a  case  of  Asiatic  cholera." 

As  a  matter  of  fact,  however,  the  strongly  marked  features  that  make 
qiiick  differential  recognition  easy,  are  often  observed  only  so  near  the 
end  of  a  fatal  attack  that  the  announcement  of  death  may  be  almost 
simultaneous  Avitli  the  establishment  of  a  positive  diagnosis. 

Suppose  Ave  have  vomiting  and  purging,  a  livid  hue  appearing  first 
at  the  periphery  then  spreading  over  the  body  and  deepening  to  marked 


PSEUDO-ASIATIC  CHOLERA.  995 

cyanosis,  a  feeble,  filiform,  fading  pnlse,  even  visible  emaciation,  character- 
ized by  sinking  of  the  eyes  into  their  orbits,  hollow  cheeks,  and  empty 
temples;  let  there  be  violent  muscular  cramps,  a  cold  skin  and  cool  breath, 
a  husky  voice,  a  constant  craving  for  drink  with  extreme  exhaustion; 
finally  even  allow  the  stools  to  resemble  rice-water,  and  we  are  yet  com- 
pelled to  state  that  every  single  symptom  and  all  combined  may  occur  in 
violent  cholera  morbus,  where  no  specific  infection  has  taken  place,  and 
where  in  consequence  there  is  no  fear  of  spreading  contagion.  It  would 
be  folly  to  attempt  to  disguise  the  fact  that  simple  cholera  may  assume  this 
grave  type  and  even  end  in  death.  Cases  of  this  kind  are  frequently  re- 
sponsible for  the  rumor  that  Asiatic  cholera  has  invaded  a  place.  It  is 
only  the  sequel,  i.e.,  the  absence  of  spi-eading  infection,  that  permits  a  real 
diagnosis. 

As  the  subject  of  pseudo- Asiatic  cholera  is  both  interesting  and  instruct- 
ive, it  will  not  be  amiss  to  select  a  few  typical  cases  at  random,  from  the 
large  number  that  have  been  from  time  to  time  observed.  The  cases  are 
all  recent  ones,  and  some  of  them  have  not  hitherto  appeared  in  print. 

Case  1.  Rapidly  Fatal  Sporadic  Cholera. — The  following-  case  was  observetl 
by  Drs.  J.  G.  Johnson  and  Jewett  of  Brooklyn,  on  July  9th,  1874.  The  patient, 
Maiy  Ann  Harrison,  64  years  of  age,  well  preserved  and  temperate,  was  seized 
suddenly  about  midnight  with  purging",  vomiting  and  most  violent  cramps  in  the 
back,  sides  and  calves  of  the  legs.  The  countenance  was  pinched,  the  skin  of  the 
hands  shriveled,  and  the  breath  was  cold.  Rice-water  discharges  followed  eacit 
other  in  rapid  succession,  the  vomiting  was  frequent  and  increased  the  pain  and 
distress.  The  patient  was  perfectly  rational  in  the  intervals  of  freedom  from  pain,, 
.  and  was  able  to  give  an  accovmt  of  the  beginning  of  the  attack.  The  following 
morning  there  was  a  slight  effort  at  reaction,  but  the  patient  sank  steadily  and 
died  in  collapse  within  24  houi-s  after  the  beginning  of  the  seizure.  A  catheter 
introduced  shortly  before  death  failed  to  detect  any  urine  in  the  bladder.  The 
circumstances  attending  the  appearance  of  this  case  are  thus  described  by  Dr. 
Johnson:^ 

A  man  named  Callahan,  had  purchased  a  cargo  of  damaged  fire-crackers  and 
had  stored  350  boxes  in  the  room  adjoining-  that  which  Mrs.  Harrison  occupied. 
These  crackers  had  been  on  a  three-months  voyage  from  China  in  a  leaky  ship  and 
had  become  thoi'oughly  soaked  with  the  leakag"e  and  the  bilge  water.  The  room  had 
a  southern  exposure,  and  the  hot  broiling  sun  had  produced  such  a  decomposition 
of  this  immense  mass  of  vegetable  matter  that  the  boxes  had  dropped  apart, 
even  the  wood  of  theiu  being  rotten,  and  the  paper  of  the  boxes  and  of  the  fire- 
crackers being  reduced  to  a  rotten  pulp.  This  room  communicated  with  the  room 
Mrs.  Harrison  occupied  by  folding  doors  (parlors);  these  from  the  settling  of  the 
house  did  not  completely  close,  but  left  a  crack  of  about  an  inch,  through  which 
all  this  miasm  from  heat,  moisture  and  decomposing  vegetable  matter  escaped  into 
Mrs.  Harrison's  room.  Her  bed  was  against  the  doors  on  the  other  side.  As  if 
this  was  not  enough,  the  man  had  placed  on  the  roof  of  the  extension  in  the  hot 
sun  masses  of  these  crackers  taken  out  of  the  boxes,  and  a  thunder-storm  coming 
up  after  they  had  been  thoroughly  wetted,  they  were  put  back  into  this  room  for 
the  sun  of  a  July  day  to  dry  them,  and  no  means  of  escape  for  the  effluvia  except 
into  Mrs.  Harrison's  i-oom.  Other  times  wet  crackers  were  placed  upon  the  roof 
to  diy,  and  the  stench  was  so  great  that  the  family  up-stairs  swept  them  off  on  the 
grovind,  wlien  they  were  left  to  the  alternate  moisture  of  the  rains  and  the  heat 
of  the  sun,  till  this  mushy  pulp  would  feel  under  your  feet  like  soft  brewer's  grains. 

Case  2.  Aggravated  Cholera  3Iorbus  simulating  Cholera  Asiatica. — The 
following  is  a  brief  account  of  a  case  occurring  in  the  practice  of  Dr.  E.  C.  Har- 
wood,  of  New  York,  in  the  summer  of  1877,  and  wliich  he  reported  to  the  authori- 
ties as  one  of  Asiatic  cholera.  Peter  Van  K.,  ag-ed  51,  a  letter  carrier,  had  always 
been  healthj^  with  the  exception  of  occasional  slight  bilious  attacks.  On  July  13'th 
he  felt  rather  poorly  and  expected  one  of  his  usual  attacks,  but  the  following  day 
was  apparently  as  well  as  ever.  The  next  Aa.\,  which  was  Sunday,  he  was  in  ex- 
cellent spirits  and  took  a  drive  with  his  wife  in  the  morning",  but  had  no  appetite 
for  his  dinner  and  complained  of  feeling-  poorly  all  the  afternoon.  On  Monday 
afternoon  he  was  seized  with  vomiting  and  purging  with  cramps  in  the  abdomen. 


296  ASIATIC  CHOLERA. 

Wlien  seen  a  few  houi-s  later  he  was  sitting-  on  a  sofa,  veiy  pale,  with  a  pinched 
and  anxious  expression  on  his  face;  the  eyes  were  sunken,  the  pulse  was  quick 
and  feeble,  and  the  skin  cool.  After  prescribing  for  the  patient  Dr.  Harwood  left, 
intending-  to  return  a  few  houi-s  later,  but  was  soon  called  again.  At  this  time 
the  man  was  veiy  restless,  the  face  was  more  pinclied,  and  the  skin,  especially'  of 
the  hands,  was  pale  and  covered  with  a  cold  clammy  pei"spiration,  and  presented 
the  characteristic  "  washerwoman's  appearance."  The  prostration  was  marked, 
the  breath  was  cool,  the  voice  was  husky,  there  were  cramps  in  the  flexor  muscles 
of  the  legs,  the  pulse  was  quick  and  very  feeble,  and  the  tempei-ature  slightly 
subnormal.  There  were  frequent  rice-water  discharges  from  the  bowels.  The 
patient  died  early  the  following-  morning-,  less  than  twenty-four  liours  after  the 
beginning-  of  the  attack.  Some  time  after  death,  on  moving  the  body  unmistak- 
able contractions  took  place  in  the  arm  and  fingers,  and  a  thermometer  placed  in 
the  axilla  registered  108'  F. 

The  certificate  of  death  from  collapse  induced  by  cholera,  was  refused  bj'  the 
Board  of  Health,  and  tlie  case  was  put  into  the  coroner's  hands.  At  the  autopsj^, 
made  thirty-two  hours  after  death,  the  stomach  was  found  to  contain  about  half 
a  pint  of  watery  fluid  of  the  color  of  oatmeal.  The  mucous  membrane  was  pink- 
ish and  injected  in  spots,  eroded  and  could  be  easily  stripped  off.  The  small  in- 
testines contained  the  same  sort  of  fluid.  There  was  no  marked  projection  of 
either  the  solitary  or  agminated  glands,  and  tlie  mucous  membrane  was  pale 
with  here  and  there  little  points  of  congestion.  The  coroner  gave  a  certificate  of 
aggravated  cholera  morbus. 

Case  3.  Sporadic  Cholera. — Dr.  Tripp,  in  the  Louisville  Medical  News,  Decem- 
ber 37, 1884,  reports  the  following  cases  occurring  in  the  practice  of  Dr.  Pennebaker: 
Mr.  A.  K.,  aged  fifty,  single,  farmer,  well  developed  and  nourished,  previous 
health  good,  was  suddenly  attacked  on  the  afternoon  of  August  30th,  about  four 
o'clock  p.  M. ,  with  vomiting  and  purging.  He  had  been  in  his  usual  health  up  to  that 
time.  There  was  no  prodromic  diarrhoea  or  nausea.  The  purging  and  vomiting 
recurred  at  intervals  of  ten  or  fifteen  minutes  for  about  two  hours,  when  he  be- 
came wholly  unconscious.  The  stools  were  preceded  by  little  or  no  pain,  and 
emesis  by  no  nausea.  When  I  called  the  patient  was  comatose,  and  in  collapse. 
Pulse  not  perceptible;  skin  cold,  clammy-,  and  of  a  color  resembling  the  "bluish, 
leaden-hued  skin  of  epileptics  after  the  long-continued  use  of  nitrate  of  silver." 
The  pupils  were  dilated  and  the  respirations  were  not  perceptible. 

As  he  had  been  in  this  extreme  condition  but  a  short  time,  artificial  respiration 
Avas  applied  at  once.  Tlie  bowels  moved  spontaneously.  The  stools  were  odor- 
less, watery,  and  contained  the  "  rice-grain  "'  dejiosit.  Respiration  showed  a  ten- 
dency to  return.  Morphine  suIjdIi.  was  given  hy  mouth,  and  hot  applications 
made  to  the  extremities  and  abdomen.  Respiration  was  resumed  without  further 
assistance  in  a  few  minutes.  The  patient  vomited  the  morphine,  and  more  was 
given  hypodermically.  Consciousness  returning,  severe  cramps  in  the  muscles 
of  the  calves  were  complained  of. 

As  soon  as  the  patient  had  revived  sufficiently  to  know  those  around  him,  the 
purging  again  induced  the  condition  of  collapse,  making  artificial  respiration  once 
more  necessary.  Morphine  was  given  under  the  skin.  He  became  conscious, 
and  in  the  course  of  an  hour  the  purging  ceased.  I  ordered  an  enema  of  one  drachm 
tincture  of  opium  in  starch-water,  repeated  every  two  hours  until  four  o'clock  a.m., 
when  the  bowels  were  checked.  The  pulse  was  weak,  slow,  and  in-egular,  and 
the  mental  faculties  sluggish.  The  thii"st  was  intense.  The  patient  vomited 
sevei'al  times.     Ordered 

Quinife  sulph li. 

Acid,  sulph.  aromat 3  iv. 

Syrupi '-  Ha  =  i 

Aqua}  dest \    '  -"  •■' 

M.  Sig. :  One  drachm  eveiy  two  hours,  alternated  with  pepsin  gr.  v. 

August  31st,  P.M.,  the  pulse  was  about  one  hundred,  and  weak,  the  skin  in- 
active and  cold.  The  kidney's  acted  for  the  first  time  at  noon,  but  the  secretion 
was  scanty.     The  patient  complained  of  lumbar  pain. 

Convalescence  was  slow  but  not  cliaracterized  by  the  typhoid  conditions  Avhich 
so  often  follows  reaction.    Dr.  Tripp  makes  the  following-  comments  on  this  case: 

The  clinical  history  presents  all  of  the  symptoms  of  a  so-called  fulminant  case 
of  true  cholera.  Tiie'  first  thing  noticed  is  an  absence  of  all  prodromal  sj'mptoms 
which  in  tiie  majority  of  cases  occur;  next,  the  early  appearance   of  the  algid 


PSEUDO-ASIATIC   CHOLERA.  997 

stage,  which  natvirally  would  appear  at  an  earlier  period  witli  pi-odroniic  symp- 
toms absent.  In  this  condition  the  patient  was  to  all  appearances  moribund,  the 
I'espirations  and  pulse  being-  imperceptible,  and  the  resort  to  artificial  respiration 
would  seem  to  have  been  the  only  thing  that  could  coax  the  ebbing  tide  of  life 
back  again.  It  is  to  be  regretted  that  the  thermal  range  was  not  taken,  both 
duringthe  stage  of  collapse  and  after  reaction  had  set  in.  As  far  as  could  be  dis- 
covered without  the  thermometer,  the  fever  during  reaction  did  not  run  very 
high,  or  continue  longer  than  a  day  or  two.  The  muscular  cramps  in  the  extrem- 
ities and  suppression  of  urine  were  marked  features.  The  ui-ine  was  not  tested 
for  albumen.  Absence  of  uremic  symptoms,  and  also  of  the  typhoid  condition 
during  convalesence,  would  appear  rather  exceptional  when  we  take  into  ac- 
count the  gravity  of  the  case.  However,  recovery  was  slow,  with  considei-- 
able  gastro-intestinal  irritation. 

Case  4.  Choleraic  Diarrhoea. — Under  this  heading  Alex.  W.  Stirling,  M.  B., 
of  Stapleton,  Cumberland,  records  in  a  recent  issue  of  the  British  Medical  Journal, 
the  following  case: 

On  the  forenoon  of  July  22d,  I  was  sent  for  to  visit  Mrs.  C.  She  had  been 
a  woman  of  fair  health  and  of  a  ruddy  complexion.  She  was  in  her  sixtj'-fifth 
year.  She  had  been  suddenly  seized,  the  previous  evening,  by  cramps  in  the  back 
of  the  legs  and  thighs,  and  in  the  abdomen,  and  by  severe  vomiting  and  diarrhoea, 
for  which  her  friends  had  administered  a  dose  of  castor-oil.  These  symptoms  liad 
grown  gradualh'  worse,  and  when  I  saw  her  her  face  was  pale  and  anxious  and 
her  skin  cold  and  damp.  Tlie  temperature  in  the  axilla  was  98°;  pulse  120,  regu- 
lar, but  very  weak.  The  cramps  recurred  every  ten  minutes,  beginning  in  the 
legs,  and  extending  upward  to  the  abdomen,  and  then  followed  immediately 
purging  and  vomiting.  So  irritable  was  the  stomach,  that  she  had  been  unable 
to  retain  any  food  since  the  previous  night;  and  there  was  no  means  of  quenching 
her  extreme'  thirst,  for  even  a  mouthful  of  water  was  returned  at  once.  Small 
quantities  of  brandy  and  water,  brandy  and  milk,  and  milk  and  lime-water,  were 
tried  without  avail"  Chlorodyne  was  given,  but  it  also  was  vomited.  Mustard 
was  applied  to  the  leg's  and  abdomen,  but  to  little  purpose,  as  I  found  when  I  re- 
turned later.  Subcutaneovis  injections  of  stimulants  now  for  a  time  somewhat 
restored  the  pulse;  but  the  improvement  was  sliort,  and  ere  long  it  had  become 
nearly  imperceptible  at  the  wrist.  In  the  evening  she  was  still  unable  to  retain 
anj'thing  in  the  stomach,  and  remained  so  till  the  end.  One-sixth  of  a  grain  of 
morphia  given  hypodermic-ally  had  relieved  the  cramp  to  some  extent;  but,  in 
spite  of  the  free  \xse  of  stimulants,  she  became  gradually  weaker,  the  voice  be- 
came husky,  and  at  midnight  she  was  in  a  state  of  collapse,  tlie  vomiting  and 
purging  ceasing  as  tliis  grew  more  marked,  till  they  completely  stopped  unless 
anything  were  taken  to  relieve  the  thirst.  The  temperature  was  always  sub- 
normal. I  did  not  see  the  vomited  matter  or  stools  at  midday;  but  in  the  after- 
noon and  evening  the  latter  were  of  a  character  corresponding  exactly  with  the 
descriptions  given  of  tliose  of  Asiatic  cholera.  The  fluid  contained  no  bile,  but 
was  clear,  thin,  and  watery,  and  had  no  ftecal  look  or  smell,  but  contained  rice- 
like bodies  in  suspension.  The  vomited  matter  varied  with  the  amount  of  liquid 
swallowed,  being  sometimes  clear  and  watery,  or  stained  slightly  green,  or  glairy 
and  containing  more  mucus,  but  I  saw  no  flocculi  in  it.  She  had  passed  no  water 
since  Monday  evening;  and  at  one  o'clock  on  Wednesday  morning  there  was  no 
sign  above  the  pubes  of  water  in  the  bladder;  but  to  make  sure  I  passed  a  catheter. 
I  found  it  absolutely  empty.  The  collapse  became  more  profound;  and  in  the 
early  morning  slie  died,  having  remained  sensible  to  the  last. 

Five  daj's  later,  her  son  consulted  me  on  account  of  watery  diarrhoea  and 
cramps  in  the  legs;  but  lead  and  opium  pills  relieved  him,  and  he  was  well  in  a 
couple  of  daj's. 

In  his  remarks  on  this  case  the  author  says:  "How  great  may  be  the  resem- 
blance of  summer  cholera  to  true  Asiatic  cholei-a,  as  exemplified  in  the  above,  and 
to  some  extent  to  poisoning  by  arsenic,  is  what  strikes  me  as  noteworthy  in  the 
above  case.  The  idea  of  the  latter  I  dismissed  from  my  knowledge  of  the  ])eople 
and  their  surroundings,  as  well  as  from  the  fact  that  the  vomiting  and  diarrhoea 
had  not  the  characters  usually  seen  in  such  cases,  noi-  was  there  any  pain  in  the 
stomach.  Had  the  case  occurred  in  a  seaport  town,  except  from  the  absence  of 
the  germ,  there  might  have  been  difficulty  in  deciding  as  to  its  nature.  Dr.  Bris- 
towe  says,  in  his  "Tlieoryand  Practice  of  Medicine,"  page  761:  'The  symptoms 
have,  in  fact,  a  close  resemblance  to  tliose  of  Asiatic  cholera,  but  diifer  from  that 
clinically  in  their  circumstances;  that  tiie  evacuations  rarelj',  if  ever,  assvuiie  the 


298  ASLVTIC  CHOLERA. 

rice-water  character  or  are  devoid  of  bile;  that  the  urine  is  not  g*enerally  sup- 
pressed; and  that  tlie  collapse  is  neither  so  sudden  nor  so  extreme  as  in  the;  epi- 
demic disease."  In  the  case  of  Mrs.  C,  the  rice-water  character  of  tlie  stools  w;us 
most  marked;  there  was  no  bile;  the  urine  was  completely'  suppi-essed,  and  collapse 
was  ]:)resent  to  a  considerable  degree  when  first  I  saw  her,  and  had  become  as  ab- 
solute as  is  consistent  with  life  within  twenty-four  hours.  If  we  suppose  the  case 
to  have  occurred  in  a  town  open  to  cholei-aic  infection,  the  illness  of  the  son, 
though  beginning  five  days  after  his  mother's  death,  might  have  been  taken  as 
evidence  in  favor  of  the  contagious  character  of  the  disease." 

Case  5.  Simple  Cholera. — In  the  "Annual  Report"  of  the  Supervising 
Sui'geon-General  of  the  Marine  Hospital  Service  of  the  United  States,  lor  the 
fiscal  year  1884,  we  find  tlie  following-  record  of  a  fatal  case  of  simple  cholera: 

C.  "W.,  aged  30  years;  nativity,  Virginia;  was  admitted  to  the  marine  ward  of 
the  Good  Samaritan  Hospital  at  Cincinnati,  Oliio,  July  9,  1883.     Died  July  12. 

History — The  patient,  a  deck-hand  from  the  steamer  Will  Kyle,  was  taken 
sick  with  "diarrhoea  several  days  before  he  made  application  tor  relief.  At  tlie 
time  of  his  admission  to  the  hospital  he  was  suttering  from  diarrhoea,  pain  in  the 
back,  thiglis,  and  calves  of  his  legs,  with  temperature  of  33.2°  C.  The  next  morn- 
ing his  temperature  was  normal,  but  rose  to  40°  C.  in  the  evening.  Simultaneous 
vomiting-  and  purging  began  about  noon  and  continued  during  tlie  day  and  night, 
accompanied  with  severe  cramping  of  the  muscles  of  the  abdomen,  back,  thighs, 
and  calves  of  the  legs.  The  dejections,  which  were  frequent  and  in  great  quan- 
tity, resembled  p»ree  de  2^ois,  and  similar  matter  was  vomited,  with  the  addition 
of  bile.  Pulse  frequent  and  feeble.  Urine  high-coJored,  free  from  albumen,  and 
scanty.  Respiration  frequent;  voice  trembling  and  feeble.  Distress  and  anxiety 
were  "marked  symptoms.  July  12,  the  day  he  died,  epistaxis  occurred,  and  coukl 
only  be  checkecl  by  plug'ging  the  posterior  nares.  His  temperature  fell  to  36°  O. : 
algid  symptoms,  resembling- tliose  of  malignant  cholera,  followed;  pinched  face; 
icy  coldness  of  the  extremities;  skin  of  hands  slu'iveled,  and  eyes  deeply  sunken. 
He  became  comatose  a  few  hours  before  death. 

Autopsy — Rigor  mortis  well  marked;  stomach  nearly  empty;  mucous  mem- 
brane intiamed  and  softened  to  such  an  extent  that  the  rugje  were  hardly  visible. 
The  inflammation  was  general,  but  did  not  extend  bej'ond  the  mucous  layer, 
which  was  much  swollen,  and  came  off  with  sliglit  pressure  of  the  fingers.  The 
vessels  of  the  small  and  large  intestines  were  distended,  giving  these  viscera  a 
deep-pink  color.  They  contained  considerable  excreta,  resembling-  the  dejections. 
Mucous  membrane  of  large  and  small  intestines  throughout  inflamed,  softened, 
and  in  places  denuded.  What  few  patches  of  Pej'er  and  solitary  glands  could 
be  recognized  were  much  swollen.  Peritoneum  not  inflamed.  Liver  congested; 
gall-bladder  full,  and  ducts  free.  Kidnej's  anaemic  but  not  diseased.  Spleen 
somewhat  enlarged.  Hj'postatic  congestion  of  posterior  border  of  both  lungs  and 
hepatization  of  the  base  "of  each.  Rigiit  side  of  Heart  contained  a  little  blood. 
Blood  in  heart  and  arteries  about  the  color  and  consistence  of  black  molasses. 
Brain  not  examined. 

Case  6.  Simjile  Cholera. — The  following  is  a  succinct  account  of  a  case  of 
simple  cholera  of  unusual  gravit}^  which  occurred  recently  in  the  practice  of  the 
editor. 

Mr.  R.,  ffit.  53;  German.  He  was  of  temperate  habits  although  his  occupation, 
of  restaurant  keeper  necessitated  a  certain  amount  of  irregularity'.  I  was  sum- 
moned in  great  haste  at  5  a.m.  to  see  him,  as  he  was  supposed  to  be  dying.  This 
happened  during  the  heated  term  in  August,  1884. 

The  patient  was  found  in  complete  collapse,  livid,  cold,  pulseless,  but  moaning 
from  pain  occasioned  by  muscular  cramps.  Vomiting-  and  purging  had  come  on 
only  six  or  seven  hours  ago.  The  discharges  had  within  the  past  hour  assumed 
a  watery  consistence,  and  occurred  about  once  in  fifteen  minutes.  Nothing  had 
been  retained  by  the  stomach  for  several  hours,  yet  vomiting  still  continued. 
The  poor  sufferer  looked  indeed  moribund,  yet  his  intelligence  was  retained,  and 
in  a  husky  whisper  he  called  constantly  for  cold  drinks.  No  symptom  belonging 
to  the  collapse  stage  of  Asiatic  cholera  seemed  wanting. 

Hypodermics  of  camphor  dissolved  in  ethei*,  brandy,  and  after  a  while  one- 
thirdof  a  grain  of  morphine  were  given.  Heat,  friction,  sinapisms,  were  liberally 
employed,  and  to  my  great  surprise  and  satisfaction  the  patient  rallied  inside  of 
two  hours.  Suffice" it"  to  say  that  he  made  a  rapid  and  complete  recover^'.  As 
soon  as  purging  had  ceased  the  rectal  temperature  was  found  to  be  100.5'  F. ;  the 
axillary  temperature  could  not  be  taken  on  accouut  of  the  restlessness  of  the 
patient. 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.  9  99 

Such  cases  could  be  multiplied  ad  libitum.  But  it  seems  unnecessary 
to  adduce  further  isolated  evidence  in  support  of  the  assertion  that  our 
ordinary  clinical  methods  are  at  times  insufficient  to  warrant  a  differential 
diagnosis.  And  that, therefore,  it  has  often  been  found  imperative  to  "await 
developments"  before  giving  an  absolute  and  definite  opinion  whether 
simple  or  Asiatic  cholera  was  present. 

One  of  the  most  recent  writers  on  cholera.  Dr.  Stille,'  has  so  well  ap- 
preciated and  demonstrated  this  difficulty,  that  in  view  of  the  intrinsic 
importance  of  the  subject  Ave  here  insert  a  quotation  from  his  article. 
Speaking  of  the  most  characteristic  symptoms  of  Asiatic  cholera,  he  says: 

But  every  one  of  those  symptoms  may  occur  in  cholera  morbus  produced  by  a  di- 
rect irritation  of  the  stomach  and  bowels.  It  is  ratlier  theii*  nature,  we  repeat,  than 
tlieir  jihenoniena  that  distinyuislies  tiiese  two  affections  from  eacli  otiier.  In  at- 
tempting to  separate  Asiatic  cliolei-a  from  other  forms  of  cholera  we  must  en- 
deavor to  dismiss  from  the  mind  the  erroneous  notion  that  tlie  term  cholera 
denotes  a  definite  disease  identical  in  its  cause,  phenomena  and  results.  It  is  no 
more  a  disease  than  dropsy  or  fever  is  a  disease.  It  is  a  complex  group  of  symp- 
toms which  have  in  common  the  fact  that  they  proceed  directly  from  the  gastro- 
intestinal irritation,  whose  degree  of  severity-^le.,  the  presence  or  absence  of 
certain  grave  symptoms — and,  above  all,  its  issue,  depend  chiefly  upon  the  nature 
and  intensity  of  the  cause  of  the  attack,  and  also,  necessarily,  upon  the  degree 
of  resistance  opposed  to  it  by  the  subjects  of  the  disease.  Nothing-  lias  led  to 
more  error  in  regard  to  epidemic  cholera  than  the  ignorance  of  this  pathological 
fact  by  some  and  the  disregard  of  it  by  others. 

Further  on  he  writes  as  follows: 

The  Greek,  Roman  and  Arabian  conceptions  of  cholera  morbus  included  a 
discharge  of  bile,  the  very  symptom  for  the  absence  of  which  Asiatic  cholera  is 
notorious;  and  also  that  the  classical  cholera,  or  cholera  moi-bus,  ended  in  recov- 
ery even  inore  frequently  than  Asiatic  cholera  terminates  in  death.  But  local 
epidemics  of  cholera  morbus  sometimes  take  place  which  are  of  a  severe  and  even 
of  a  grave  type,  and  which  also  appear  to  originate  in  some  peculiar  atmospheric 
influence,  for  they  prevail  to  a  limited  extent  and  in  connection  with  vicissitudes 
of  weather.  Still  more  circumscribed  epidemics  have  been  traced  to  unwhole- 
some food  and  drink,  and  innumerable  instances  of  individual  attacks  have  been 
caused  by  irritants  that  are  ranked  as  poisons  and  others  which  are  reckoned  as 
food  or  medicines. 

Macpherson,^ -after  a  detailed  discussion  of  the  subject,  says:  "  Cholera 
indica  is  essentially  a  very  fatal  disease,  while  cholera  nostras  is  usually  a 
mild  affection  and  is  seldom  fatal,  although  it  was  called  atrocissimus  et 
2)eracutus,  and  has  undoubtedly  killed  in  from  eight  to  twenty-four  hours." 

Yet  he  freely  admits  that  there  is  not  a  single  symptom  that  is  pathog- 
nomonic of  either  disease. 

In  this  place  the  writer  may  be  allowed  to  quote  from  a  recent  article 
by  himself,  published  in  The  Medical  Record  of  November  29th,  1884, 
which  called  attention  more  particularly  to  the  necessity  of  bacterio- 
scopy  for  diagnostic  purposes: 

"  It  is  obvious  that  the  earliest  possible  recognition  of  the  very  first  case 
of  cholera  that  might  appear  among  us  Avould  give  us  the  best  chance  for 
prompt  action  to  prevent  any  extension  of  the  disease.  Now,  it  is  a 
lamentable  fact  that  the  most  careful  analysis  of  symptoms  does  not  always 
enable  us  to  distinguish,  in  a  given  case,  cholera  morbus  from  genuine 
Asiatic  cholera.  Indeed,  it  is  held  by  some  physicians  that  the  two  dis- 
eases differ  in  degree  only,  and  not  in  kind. 

"Without  stopping  to  consider  this  point,  we  must  yet  face  the  fact 

'  Loc.  citat. ,  p.  750. 

-  Medical  Times  and  Gazette,  December,  1870,  p.  725. 


300  ASIATIC  CHOLERA. 

that  our  usual  methods  are  inadequate  to  differentiate  with  absolute  cer- 
tainty an  attack  of  violent  and  fatal  cholera  morbus  from  one  of  true 
cholera.  The  kind  of  reasoning  hitherto  employed  by  physicians  has  nec- 
essarily been  of  the  a  posteriori  variety.  That  is  to  say,  if  a  suspicious 
case  recovered,  and  was  not  soon  followed  by  other  and  rapidly  fatal  cases, 
the  disease  was  classed  as  cholera  morbus.  If,  on  the  other  hand,  the  first 
suspicious  case  was  quickly  followed  by  an  increasing  number  of  fatal 
cases,  the  diagnosis  of  Asiatic  cholera  was  subsequently  made.  Mani- 
festly, a  method  of  this  kind  might  give  the  cholera  a  chance  to  secure  a 
dangerous  foothold  before  being  recognized  as  such;  and  one  need  not  be 
an  alarmist  to  entertain  grave  apprehensions  should  such  a  misfortune 
befall  us.  But  in  view  of  recent  discoveries,  it  now  seems  possible  to 
decide  positively  and  in  a  very  short  time  Avhether  we  arc  dealing  with 
the  comparatively  benign  cholera  nostras,  or  with  the  eminently  malignant 
Asiatic  cholera. " 

And  further,  "  in  scientific  bacterioscopy  we  have  quite  possibly  a  ready 
means  of  detecting  with  certainty  the  existence  of  cholera."  Since  tlie 
above  was  written  the  editor  has  not  had  reason  to  change  his  views.  lie 
still  believes  that  competent  persons  may  be  able  to  decide  from  micro- 
biological evidence  which  disease  we  are  dealing  Avith.  But  of  course 
it  is  to  be  admitted  tbat  others  hold  a  different  opinion,  and  confidently 
assert  that  the  various  attributes  of  the  comma-bacillus  furnish  insulhcient 
and  utterly  unreliable  data  upon  which  to  base  a  differential  diagnosis. 
From  the  same  article  the  following  is  also  taken,  as  having  a  bearing  on 
the  subject  under  consideration: 

But  in  order  to  faniiharize  oureelves  with  the  necessary  details  of  these  modern 
methods,  eamiest  study  and  some  expei'ience  are  essential.  I  hold  that  we  have 
not  the  right  to  ignore  the  light  that  has  been  slied  on  tlie  true  nature  of  infectious 
diseases  by  the  keenly  searching  spirit  of  modern  experimental  inquiry.  .  .  . 
Let  the  State  Health  Boards  organize  properh^  equipped  laboratories  for  the  pur- 
pose of  affording  suitable  facilities  for  this  kind  of  study  and  researcii.  Individual 
physicians  with  sufficient  time  and  private  means  should  take  iiu  active  interest 
in  all  that  relates  to  the  examination  and  cultivation  of  bacteria.  Is  the  medical 
profession  of  our  country  to  be  put  to  shame  by  its  attitude  of  apathy  toward 
matters  of  serious  concern  to  the  public  welfare?  Are  we  to  be  made  the  laugh- 
ing stock  of  our  transatlantic  confreres  ?  Two  well-known  physicians  of  our  country 
have  already  attempted  to  overthrow  the  diagnostic  significance  of  the  bacillus  of 
tubercular  consumption,  the  one  by  claiming  it  to  be  a  fat-ciystal,  the  other  by 
asserting  its  identity  with  shi'eds  of  fibrin.  But  neither  the  one  nor  the  other  had 
at  the  time  of  his  pretended  discovery  ever  beheld  the  ti'ue  bacillus  tuberculosis. 
To  avoid  similarly  ridiculous  errors  we  need  expei-t  teachers  of  bacterioscopy. 

'And  further: 

Koch's  conclusions  wei'e  accepted  without  hesitation  by  those  who  knew  him 
best,  and  who  have  had  occasion  to  witness  his  conscientious  and  painstaking 
methods  of  conducting  all  scientific  work.  Thus,  in  Germany,  Herr  Von  Gossler, 
Minister  of  Public  Worship,  Education,  and  Medical  Affairs,  has  already  ordered 
that  a  certain  number  of  medical  men  are  to  be  summoned  to  Berlin  every  year 
to  go  through  a  course  of  study,  lasting  from  a  fortnight  to  three  weeks,  in  order 
to  learn  the  new  methods  of  investigation  connected  with  bacteria  and  micro-or- 
ganisms, but  ciiiefly  to  become  acquainted  with  everything  connected  with  the 
comma-bacillus  and  tiie  methods  of  cultivating  il  according  to  Koch's  method. 
The  several  Federal  Governments  have  been  likewise  officially  requested  to  select 
a  number  of  medical  men  for  these  com-ses  and  to  inform  them  to  hold  themselves 
in  readiness  to  come  to  Berlin.  In  our  own  country,  however,  there  is  still,  even 
in  the  ranks  of  the  medical  profession,  an  unfortunate  disposition  to  regard  the 
entire  svibject  of  bacteria  as  trivial  or  fanciful,  and  unworthy  of  serious  consider- 
ation. 


DIAGNOSIS.  301 

And  finally,  concerning  the  present  status  of  this  kind  of  investigation 
it  was  said: 

That  scientific  bacteriology  is  as  yet  in  its  infancy  all  will  admit.  But  let  us 
not  blindly  ignore  its  actual  accomplishments.  We  may  never  be  able,  perhaps, 
to  completely  eradicate  consmiiption  or  suppress  all  contagious  diseases,  but  at 
present  we  are  without  the  slightest  doubt  nearer  to  such  a  desirable  consumma- 
tion than  we  were  before  the  era  of  bacterioscopy. 

In  tliis  place  allusion  may  also  be  made  to  the  recent  debate  upon 
cholera  which  took  place  before  the  Royal  Medical  and  Chirurgical  Society.* 
Mr.  Che3"ne,  who  studied  the  subject  during  the  Paris  epidemic  of  1884, 
replying  to  the  contrary  assertions  of  Klein,  positiyely  showed  that  Koch's 
cholera  bacillus,  whether  comma-shaped  or  not,  possessed  unmistakable 
characteristics,  sufficient  to  separate  it  from  all  other  known  bacteria.  It 
was  clearly  a  distinct  species.  It  is  significant  that  Klein  was  compelled 
to  acknowledge  that  the  curyed  mouth-bacilli  had  to  be  grown  in  media 
different  from  those  of  the  curyed  cholera-bacilli,  in  order  to  make  the 
respectiye  cultures  look  alike.  This  alone  is  a  positive  proof  of  the  fact 
the  cholera  commas  are  as  distinctly  different  from  the  similarly  shaped 
buccal  organisms  as  they  are  from  the  Finkler  microbe,  and  the  cheese- 
spirillum  of  Deneke.  But  it  does  not  follow  from  this  that  Koch's  com- 
mas must  be  causiitiye,  even  if  they  are  clearly  diagnostic  of  Asiatic  cholera. 

In  an  editorial  article  on  the  above  debate,  a  leading,  medical  journal  ^ 
remarks  that  "  the  establishment  of  a  causal  connection  between  the 
comma-bacillus  and  cholera  is  of  far  less  practical  importance  than  this 
other  achievement,  "which,  it  would  appear,  may  now  be  fairly  credited 
to  him,  i.e.  Koch;  namely^  that  he  has  supplied  us  with  a  means  of  diag- 
nosing Asiatic  cholera  in  the  early  stage.'' 

So,  too,  in  a  critical  review  of  this  recent  English  discussion  Dr. 
Gaffky  ^  has  shown  that  the  objections  of  Klein  cannot  be  upheld,  and 
that  they  have  by  no  means  invalidated  the  conclusions  of  Koch,  es- 
pecially with  regard  to  the  possibility  of  reaching  an  early  diagnosis,  if 
careful  search  be  made  for  the  cholera-microbe. 

But  to  resume:  While  we  must  admit  that  the  most  careful  scrutiny 
of  clinical  phenomena  will  not  always  suffice  for  diagnosis;  while,  except- 
ing the  diarrhoea,  every  one  of  the  usual  signs  may  be  missed,  and  yet  the 
patient  die  of  cholera,  we  must  nevertheless,  emphasize  those  clinical 
symptoms  that  are  of  decided  value  in  arriving  at  a  correct  diagnosis. 

The  discharge  from  the  bowels  constitutes  tlie  first  symptom,  both  in 
point  of  time  and  as  regards  actual  importance,  that  demands  attention. 
Considered  alone  there  is  nothing  decisive  or  pathognomonic  about  this 
sign.* 

Yet  when  copious  watery  dejections  follow  an  ordinary  diarrhcea,  or 
mark  the  incipience  of  disease,  when  they  occur  with  increasing  frequency 
and  losing  all  fecal  odor  and  appearance,  assume  a  rice-water  likeness, 
we  may  surmise  cholera.  If  a  careful  history  of  the  patient  is  taken,  re- 
sulting in  the  exclusion  of  irritant  poisoning,  and  if  we  have  reason  to 

'  London  Lancet,  March  28,  1885. 

2  The  British  Medical  Journal,  April  4,  1885. 

3  Deutsche  Medicinische  "Wochenschrift,  April  16,  1885,  p.  250. 

*  The  finding  of  the  comma-bacilli  in  suspected  discharges  is  purposely  left  out  of 
consideration  in  this  place;  for  many  may  not  be  willing  to  accept  that  kind  of 
e\-idence  as  conclusive.  And  of  those  who  have  this  willingness,  a  large  propor- 
tion may  lack  the  time  and  training  necessary  to  obtain  satisfactory  proofs  of 
their  specific  identity. 


302  ASIATIC  CHOLERA. 

"believe  tliat  he  may  have  been  exposed  in  some  way  to  infection  with 
Asiatic  cholera,  even  thoiigh  there  has  occurred  no  similar  case  in  the 
locality  where  he  then  is,  we  may  safely  say  that  the  case  is  one  of  Asiatic 
cholera.  If  there  is  no  history  of  possible  infection  and  the  case  occurs  in 
a  seaboard  town,  we  must  nevertheless  regard  it  with  grave  suspicion. 
In  the  smaller  inland  toAvns,  where  communication  with  other  places, 
states  and  foreign  countries  is  at  a  minimum,  a  case  of  that  kind  may 
be  regarded  with  less  suspicion,  but  should  nevertheless  be  closely  watched. 

Again  the  abrupt  appearance  of  copious  rice-watery  discharges,  quickly 
followed  by  vomiting,  collapse,  cyanosis  and  other  marked  symptoms  that 
need  not  be  repeated  here,  will  Justify  a  diagnosis  of  cholera  Asiatica,  espe- 
cially if  the  possibility  of  infection  cannot  be  positively  excluded. 

Other  valuable  diagnostic  signs  may  not  be  ignored.  The  exceedingly 
rapid  cooling  of  the  surface  of  the  body  is  certainly  quite  uncommon  in 
ordinary  diarrhoea,  or  simple  cholera  morbus.  In  Asiatic  cholera,  as  we 
have  seen,  it  is  the  rule.  So,  too,  the  speedy  fading  away  of  the  pulse, 
and  especially  the  development  of  deep  cyanosis  are  exceptional  occur- 
rences, even  in  severe  cholera  morbus.  Another  valuable  sign  is  afforded 
by  the  quick  interference  with,  or  the  complete  suppression  of,  various 
secretions.  This  is  likewise  hardly  ever  seen,  to  the  same  extent,  in  other 
diseases. 

Painful  muscular  cramps,  occurring  when  there  are  only  mild  diarrhoeal 
manifestations,  should  always  put  us  on  our  guard.  When  all  these  symp- 
toms occur  in  orderly  sequence,  as  has  been  fully  set  forth  under  symp- 
tomatology, they  constitute  a  formidable  array  of  evidence  for  a  safe 
diagnosis.  Should  the  patient  live,  the  cycle  may  be  made  yet  more 
complete  by  the  supervention  of  those  tlisturbances  that  have  been  detailed 
in  describing  the  period  of  reaction,  and  under  complications  and  sequelae. 
A  simple  diarrhoea  or  an  attack  of  cholera  morbus  is  scarcely  ever  followed 
by  a  train  of  morbid  manifestations  that  in  Asiatic  cholera  are  common 
events.  So  that  if  indecision  characterized  the  physician's  judgment  at  first, 
it  may  be  replaced  by  relative  certitude  later  on.  A  fatal  issue  need  not, 
therefore,  be  awaited  before  a  definite  opinion  is  formulated. 

There  are  yet  other  aids  to  diagnosis.  Simple  cholera  can  generally 
be  traced  back  to  a  definite  exciting  cause,  be  that  some  alimentary  dis- 
turbance, an  irritant  poison,  cold,  debauch,  or  any  other  agency  capable 
of  producing  intestinal  mischief.  The  development  of  the  disease  is  often 
much  slower  than  in  Asiatic  cholera,  though  at  times  the  reverse  obtains, 
and  cholera  morbus  is  developed  with  startling  abruptness.  No  matter 
how  profuse  the  diarrhcea  may  be,  the  evacuations  but  rarely  lose  all 
trace  of  fecal  odor  in  simple  cholera.  Again,  though  it  may  lose  its 
color  completely,  yet  the  characteristic  rice-water  appearance  of  the 
genuine  cholera-stool  is  only  exceptionally  found. 

The  vomiting  of  sporadic  cholera  generally  occurs  before  purging,  the 
stomach  being  first  to  suffer  in  the  vast  majority  of  cases.  In  Asiatic 
cholera  Ave  have  seen  that  vomiting,  as  a  rule,  follows  the  purging  by  a 
definite  interval. 

Limpid  fluid  is  hardly  ever  thrown  up  from  the  stomach  in  simple 
cholera,  whereas  it  is  rarely  missed  in  the  Asiatic  variety.  Bloody  stools 
are  unknown  in  cholera  morbus;  in  grave  cholera  Asiatica  they  are  at 
least  not  very  infrequent.  The  flabby,  doughy  condition  of  the  abdomen 
with  the  physical  signs  of  accumulating  fluid  in  the  intestines,  belongs  to 


DIFFEEENTIAL   DIAGNOSIS.  303 

Asiatic,  but  not  to  simple  cholera.     Pra?cordial  oppression.,  great  anxiety, 
intense  dyspnoea  are  absent  in  simple,  often  present  in  Asiatic  cholera. 

Cholera  morbus  may  lead  to  livid  collapse,  yet  the  skin  rarely  assumes 
the  icy  coldness  and  deep  purple  or  blackish  hue,  observable  in  epidemic 
cholera.  The  marked  loss  of  cutaneous  elasticity,  resulting  in  the  per- 
sistence of  pinched-up  folds  of  skin,  is  part  and  parcel  of  the  latter  but 
not  of  the  former  malady.  Complete  suppression  of  urin9,  Avhich,  as  has 
been  shown,  is  quite  common  in  Asiatic,  is  exceedingly  rare  in  simple 
cholera,  although  even  in  the  latter  affection  the  renal  secretion  is  often 
much  reduced  in  quantity. 

From  this  brief  svirvey  of  the  main  points  of  difference  in  the  symptom- 
atology of  simple  and  epidemic  cholera,  the  reader  Avill  infer,  what  has 
been  repeatedly  mentioned  before,  namely,  that  in  a  given  case  it  often 
requires  the  utmost  circumspection  and  the  careful  balancing  of  probabili- 
ties before  a  correct  judgment  can  be  formed.  Moreover,  that  where  a 
clear  history  is  not  obtainable,  a  differential  diagnosis  based  on  individual 
symptoms  or  groups  of  symptoms  will  frequently  be  impossible. 

It  remains  now  to  glance  at  a  number  of  morbid  states  that  have  a 
symptomatology  resembling  the  disease,  but  in  Avhich  a  painstaking  exam- 
ination will  generally  dispel  the  suspicion  or  supposition  of  actual  cholera 
Asiatica. 

Acute  intestinal  obstruction,  strangulated  hernia,  the  early  stage  of 
peritonitis,  especially  when  due  to  perforation,  violent  gastric,  hepatic  or 
renal  colic,  may  all  lead  to  such  serious  shock  that,  during  the  prevalence 
of  an  epidemic,  and  on  superficial  examination,  they  may  be  and  have 
been  regarded  as  cases  of  choleraic  collapse. 

Drasche  states  that  incipient  pneumonia,  typhoid  fever,  acute  exantliem- 
atous  diseases,  and  even  acute  tuberculosis,  have  been  mistaken  for 
cholera.  And  he  adds  that  cases  of  that  kind,  during  the  excitement 
of  an  epidemic,  are  everywhere  at  times  erroneously  classed  as  cholera. 

So,  too,  acute  intoxication  from  corrosive  su  bstances,  as  well  as  arsenical 
poisoning,  have  been  and  may  be  mistaken  for  Asiatic  cholera.  Indeed  to  the 
illiterate  lower  classes  their  undeniable  analogy  has  repeatedly  seemed  so 
striking  that  disastrous  consequences  or  at  least  threatening  popular  dis- 
turbances have  resulted. 

The  most  frequent  charge  has  been  that  the  wells  were  poisoned  by 
some  criminal.  In  the  recent  French,  Italian  and  Spanish  epidemic  (188-4) 
physicians  have  likewise  been  openly  charged  with  poisoning  their  patients. 
In  several  instances  reputable  doctors  have  been  mobbed  on  this  absurd 
supposition. 

Poisoning  by  commercial  acids,  such  as  nitric  and  sulphuric  acid,  and 
intoxication  with  coiTOsive  sublimate,  resemble  to  a  certain  extent  the 
effects  of  choleraic  infection.  The  stomach  being,  however,  always  first 
to  suffer  (unless  indeed  the  symptoms  indicate  disease  still  higher  up), 
and  a  clear  history  being  often  obtainable,  there  should  generally  be  little 
difficulty  in  differential  diagnosis. 

AVhere  irritant  poison  has  been  swallowed  the  abdominal  pain  is,  as 
a  rule,  intense,  constant,  and  burning.  Violent  paroxysmal  colic  may 
occur,  although  this  is  rather  exceptional.  Still  these  symptoms  do  not 
occur  in  Asiatic  cholera.  If  there  is  neither  smarting  pain  nor  rawness  in 
the  mouth  and  throat,  a  disagreeable  metallic  taste  often  leads  to  the 
recognition  of  intoxication. 

The  stools  are  never  as  watery  and  copious  in  poisoning  as  in  cholera. 


304  ASIATIC  CHOLERA. 

On  the  other  hand  they  are  frequently  mixed  Avith  blood,  give  forth  a 
fetid  odor,  and  occur  with  pain  followed  by  tenesmus  or  smarting  in  the 
rectum.  The  vomit  is  generally  bilious  and  bloody  in  corrosive  poisoning. 
Again,  although  the  secretion  of  urine  may  be  much  diminished,  it  is  only 
exceptionally  quite  suppressed.  Strangury  often  follows  poisoning,  or 
there  may  be  merely  vesical  tenesmus. 

The  general  appearance  of  patients  suffering  from  irritant  poisoning  is 
likewise  different  from  Avhat  is  commonly  seen  in  cholera.  There  is  less 
pinching  of  the  features,  the  cadaveric  hollowness  is  absent,  the  voice  is 
not  the  vox  cholerica,  and  though  collapse  may  be  quite  as  pronounced, 
cyanosis  never  attains  that  pitch  of  darkness  seen  in  cholera. 

Nevertheless,  cases  of  criminal  poisoning  by  arsenic  have  been  repeatedly 
mistaken  for  cholera.  Thus  Flamm  records  the  singular  case  of  a  French 
woman,  who  in  the  course  of  twent}^  years  succeeded  in  killing  over  forty 
victims  by  practicing  her  heinous  methods  during  the  prevalence  of  an 
epidemic. 

But  the  medico-legal  aspect  of  the  subject  cannot  be  fully  dealt  with 
here.  The  wary  practitioner  will  do  well  to  closely  examine  into  the  his- 
tory of  every  supposed  cholera  case  in  which  vomiting  has  preceded  the 
diarrhoea. 

The  accidental  ingestion  of  tainted  or  putrescent  foods,  e.g.,  unwhole- 
some meat  or  fish,  spoiled  milk,  butter,  cheese,  preserves,  pickles,  etc.,  also 
decomposing  fruits  or  vegetables,  may  all  lead  to  symptoms  simulating 
cholera.  Latterly  poisoning  from  canned  goods,  adulterated  foods,  bad 
beer  and  Avines  have  come  more  or  less  prominently  before  the  profession. 
These  accidents  are  merely  mentioned  in  passing,  as  possibilities  that  should 
not  be  lost  sight  of.  For  a  full  account  of  them,  the  reader  is  referred  to 
the  standard  treatises  on  toxicology  and  medical  jurisprudence. 

Finally  the  incautious  employment  of  drastic  purgatives  may  be  re- 
membered as  liable  to  give  rise  to  phenomena  of  vomiting,  purging  and 
collapse  that  Avould  be  apt  to  be  erroneously  interpreted  during  the  preva- 
lence of  cholera.  Recently  some  cases  of  poisoning  through  colehicum 
have  also  been  reported  where  the  symptoms  closely  resembled  an  attack 
of  cholera. 

As  regards  dysenteric  diseases  happening  during  the  prevalence  of 
cholera,  the  constant  presence  of  blood  in  the  dejections,  the  more  or  less 
persistent  tenesmus  should  suffice  to  preclude  errors  in  diagnosis. 

In  intensely  malarious  districts  cases  are  at  times  observed  that  may 
appear  very  puzzling  to  the  practitioner,  but  in  the  absence  of  cholera  a 
correct  diagnosis  is  always  possible  bv  a  careful  examination  of  the  patient. 
In  countries,  however,  where  cholera  is  endemic  and  malaria  is  likcAvise 
never  absent,  a  diagnosis  cannot  always  be  made.  In  his  work  on  Malaria, 
Dr.  Sternberg '  gives  the  following  account  of  the  subject; 

The  state  of  collapse  into  wliich  the  \ictim  of  an  algid  pernicious  paroxysm 
quickly  falls,  resembles  verv  closeh'  the  collapse  of  cholera,  but  the  discharges 
from  the  stomach  and  bowels,  which  are  often  quite  copious,  are  commonh'  bilious 
in  character.  A  form  of  pernicious  fever,  denominated  choleraic,  has,  however, 
been  observed,  whicli  seems  to  merit  this  name  from  the  prominence  of  the  chole- 
i-aic  symptoms,  and  from  the  fact  that  the  discharges  resemble  those  of  true 
cholera.  But  it  is  questionable  whether  the  choleraic  pernicious  fever  of  authors 
is  propei'ly  ascribed  to  the  action  of  malaria  alone.  First,  we  note  that  this  form 
is  most  common  in  regions  where  cholera  also  prevails,  and  there  is  reason  to  be- 
lieve that  the  endemic  prevalence  of  malarial  fevei-s  and  cholera  in  the  same  ter- 

'  Malaria  and  Malarial  Diseases.     New  York,  W.  Wood  &  Co.,  1884. 


CHOLERAIC   MALARIAL   FEVER.  3Q5 

intorial  limits  has  led  to  confusion  in  this  case,  just  as  in  the  case  of  typhoid  fever 
and  malaria,  and  of  yellow  fever  and  malaria,  in  regions  where  these  diseases  are 
associated. 

The  choleraic  form  of  pernicious  fever  has  also  been  observed  in  localities  far 
removed  from  the  endemic  prevalence  of  Asiatic  cholera;  but,  as  Cohn  remarks, 
it  is  especially  during-  the  season  of  g:i'eatest  heat,  when  sporadic  cases  of  cholera 
are  also  seen,  that  these  cases  occur,  and  this  author  very  properly  ascribes  the 
choleraic  symptoms  to  the  meteorological  and  local  conditions  which  produce 
cholera  nostras,  rather  than  to  the  malarial  poison  j^^r  se.  The  fact  that  the 
cholei-aic  sjTuptoms  are  an  addition  to  tliose  induced  by  the  malarial  poison  is  fur- 
ther shown  by  the  non-recurrence  of  these  sjinptoms  during  successive  parox- 
j'sms,  contrary  to  the  rule  in  ordinary  algid  pernicious  fever.  The  collapse  of 
algid  malarial  fever  differs  from  that  of  cholera  in  the  absence  of  cramps  and  in 
the  facies  of  the  patient,  which  in  the  one  case  is  calm  and  expressionless,  and  in 
other  indicates  the  suffering  caused  by  the  characteristic  cramps,  which  are  com- 
mon to  both  epidemic  and  sporadic  cholera. 

The  English  physicians  iu  India  admit  that  the  sjTiiptoms  of  cholera  and  of 
malarial  poisoning  may  coexist,  and  so  closely  are  they  often  associated  that  in 
many  cases  no  distinction  is  made,  and  the  mixed  disease  under  the  general  name 
of  fever  is  ascribed  to  malaria. 

The  same  writer,  quoting  Colin/  says  that: 

In  Cochin  China,  where  the  French  troops  suffered  severely  from  cholera,  more 
deaths  also  occurred  from  choleraic  pernicious  fever  than  from  the  other  forms  of 
pernicious  intermittent — algid,  etc. — although  outside  of  the  range  of  the  choleraic 
influence,  tliis  form  is  comparatively  rare.  The  same  fact  was  observed  at  An- 
cona  in  1865,  during  which  year  a  terrible  epidemic  of  cholera  raged  in  that  citv. 
At  the  moment  when  the  Indian  pestilence  had  almost  entirely  disappeared,  there 
occurred  still  eveiy  day  a  certain  number  of  grave  attacks,  which  led  to  the  belief 
that  it  was  still  present.  These  were  pernicious  fevers,  which  are  far  from  being 
rare  at  Ancona,  but  which  in  this  year,  under  the  influence  of  the  choleraic  consti- 
tution, manifested  themselves  in  this  form  with  unusual  frequency.  The  follow- 
ing year  tiie  cholera  was  at  the  gates  of  Civita  Vecchia,  among  the  workmen 
engaged  in  building  a  railroad  upon  the  sea-shore,  and  I  remarked  here  also  the 
augmentation  of  the  number  of  attacks  of  "choleraic  pernicious  fever"  in  our 
gari'ison  in  this  city.  It  seems  then  that  a  special  medical  constitution  favors  the 
explosion  of  attacks  of  this  kind,  whether  this  constitution  be  based  upon  the  in- 
fluence of  a  cholera  epidemic  coming  from  India,  or  simply  upon  the  elevation  of 
the  temperature,  which  in  our  countiy,  and  especially  in  England,  causes  to  occur 
each  year  some  cases  of  cholera  nostras. 

'  Traite  des  fievres  intermittentes.     Paris,  1870. 
20 


306  ASIATIC  CHOLERA 


CHAPTER  XXXVI. 

PROGNOSIS. 

Prognosis  during  the  Attack. — The  prognosis  in  a  fully-developed 
attack  of  cholera  is  always  grave.  At  tlie  very  best  it  is  uncertain.  In 
the  beginning  of  an  attack  the  visible  signs  will  perha])s  incline  the  phy- 
sician to  take  a  hopeful  view  of  the  case.  But  a  few  hours  may  witness 
so  complete  a  change  in  the  condition  of  the  patient^  that  the  last  remnant 
of  hope  will  seem  dashed  to  the  ground.  Still,  as  has  been  previously 
pointed  out,  the  almost  miraculous  can  happen,  namely,  tliat  a  patient 
apparently  moribuHd  may  speedily  experience  a  mysterious  accession  of 
new  vitality  that  carries  him  safely  through  a  rapid  convalescence  into 
a  complete  recovery.  Unfortunately,  however,  the  latter  event  is  much 
less  frequent  than  unexpected  death.  It  may  be  questioned,  in  view 
of  the  admitted  uncertainty  of  prognosis,  whether  an  attempt  to  formulate 
]'ules  is  at  all  admissible.  In  answer  it  may  be  stated  that,  while  no  disease 
shows  more  clearly  than  epidemic  cholera  the  unreliable  nature  of  human 
forethought,  nevertheless  some  signs  and  more  particularly  certain  com- 
binations of  signs,  afford  valuable  points  upon  which  a  prognosis  may  be 
based.  But  it  cannot  be  too  strongly  urged  that,  whatever  experience 
has  shown  to  l)e  the  rule,  cholera  knows  no  rule  that  has  not  its  exceptions. 

In  a  general  way  it  can  be  safely  said  that  the  mortality  of  an  epidemic 
is  greatest  in  the  early  part  of  its  aj^pearance, and,  progressively  diminishing, 
becomes  least  toward  the  end.  Now  it  is  possible  to  account  in  some 
measure  for  this  peculiarity  by  supposing  that  the  weakened,  cachectic  or 
otherwise  predisposed  are  first  attacked  and  cjuickest  to  die.  This  plau- 
sible view  of  the  matter  receives  support  also  from  the  fact  that  new- 
comers are  as  liable  to  contract  the  disease  in  the  decline  of  an  epidemic 
as  during  its  incipience. 

Stoufflet,'  for  example,  found  that  among  acclimatized  Parisians  there 
was  a  decidedly  smaller  mortality  than  among  the  ncAvly-added  population. 
In  fact,  the  history  of  all  epidemics  occurring  in  cities  furnishes  similar 
evidence. 

But  a  completely  satisfactory  explanation  of  the  high  mortality  attending 
the  early  part  of  a  cholera  demonstration  is  still  forthcoming,  even  if,  in 
addition  to  what  has  been  stated,  we  take  into  account  the  fact  that  the 
cholera  microbes  form  no  spores,  and  have  no  permanent  state. 

The  manner  of  development  of  an  attack  in  the  individual  case  is  of 
considerable  prognostic  significance.  If  there  is  no  orderly  sequence 
of  symptoms,  if  the  various  characteristic  phenomena  seem  to  break  out 
simultaneously  with  the  force  and  suddenness  of  a  great  conflagration, 

'  Le  eliolera  a  Thopital  Lariboisiere  eii  1865.     Paris,  1866. 


"II  I   (.;r  ; 
PROGNOSIS  DURING  THE'A\TTACK, 

'.''^  ft  >H;p(;Vf,,,„, 

then  the  system  is  speedily  overwhelmed,  and  a  fatal  issue  is  inevitable. 
If  in  such  cases  the  first  violent  shock  does  not  speedily  kill,  any  subsequent 
reaction  is,  as  a  rule,  imperfect  and  temporary,  or  it  assumes  the  form 
of  a  grave  typhoid  with  the  prognosis  as  bad  as  ever.  On  the  other  hand, 
Avith  a  gradual  and,  so  to  speak,  orderly  evolution  of  morbid  phenomena, 
there  is  an  avoidance  of  violent  shock,  and  the  chances  of  recovery  are 
much  better. 

Among  the  various  symptoms  of  the  disease  the  greatest  prornostic 
significance  undoubtedly  attaches  to  the  ejections,  and  of  these  the  alvine 
evacuations  have  more  importance  than  the  vomiting.  The  direct  influence 
of  the  intestinal  discharges  on  the  course  of  the  malady  has  already  been 
noticed.  When  they  are  copious,  frequent  and  very  thin,  a  bad  prognosis 
should  be  given.  When  they  show  a  tendency  in  an  opposite  direction, 
and  especially  if  they  continue  to  look  bile-stained,  some  hope  of  a  recovery 
may  still  be  entertained.  It  is  only  very  rarely  seen  that  the  stools  partake 
somewhat  of  a  fecal  character  in  cases  that  show  progressive  deterioration 
until  death. 

The  nearer  the  stools  approach  to  thin  rice-water  in  consistency,  the 
graver  the  affection.  A  somewhat  milky  appearance  augurs  better  than  a 
purely  limpid  one.  W^lien  blood  is  found  to  be  mixed  in  appreciable 
quantities  with  the  dejections,  the  prognosis  is  decidedly  bad.  According 
to  Drasche  and  other  observers,  a  fetid  chocolate-colored  discharge  signifies 
inevitable  death. 

It  happens  at  times  that,  while  intestinal  transudation  is  as  violent 
find  copious  as  ever,  the  external  discharges  are  abruptly  checked.  The 
abdomen  in  such  cases  becomes  flabby,  and  succussion  reveals  the  presence 
of  large  quantities  of  liquid.  This,  with  but  few  exceptions,  has  been 
found  to  constitute  a  fatal  sign. 

Again,  in  place  of  being  retained,  the  fluid  may  appear  to  flow  away 
in  a  steady  stream  from  the  collapsed  patient.  Incontinence  of  this  kind 
is  also  a  lethal  symptom.  When,  however,  the  external  discharges  become 
less  profuse  and  occur  at  longer  intervals,  especially  if  they  once  more 
look  bile-stained,  a  favorable  turn  may  be  expected  with  great  confidence. 
It  is  likewise  a  good  sign  if,  when  the  discharges  have  ceased,  an  exami- 
nation of  the  abdomen  shows  that  the  intestines  are  not  filling  with  liquid, 
but  rather  with  gas. 

As  regards  vomiting,  its  prognostic  significance  is  slight  when  compared 
Avith  purging.  Still,  if  the  2)atient  vomits  oftener  than  he  purges,  we 
may  look  for  a  bad  ending.  But  if  moderate  vomiting  continues,  the 
chances  are  better  than  when  it  abruptly  stops,  unless  there  be  a  simul- 
taneous amelioration  of  the  patient's  general  condition.  Indeed  if  cessation 
of  vomiting  is  accompanied  by  oppression  and  general  restlessness,  we 
are  dealing  with  a  very  grave  if  not  a  fatal  sign.  AVhen  the  ejected 
matters  become  considerably  blood-stained  or  chocolate-colored,  a  fatal 
2)rognosis  is  always  justifiable. 

Liibstorff  has  made  a  special  study  of  choleraic  vomiting.  x\ccording 
to  him  the  symptom  occurs  Avithin  the  first  tAveitty-four  hours  of  an  attack 
in  74  per  cent,  of  all  cases.  AVhen  diarrhoea  continues  Avithout  the  appear- 
ance of  vomiting,  the  chances  after  a  few  days  are  much  in  favor  of  the 
patient.  This  Avriter  goes  so  far  as  to  assert  that  diarrluea  during  an 
epidemic  of  cholera,  if  not  folloAved  by  vomiting  in  from  five  days  to  two 
Aveeks,  Avill  never  lead  to  cholera,  and,  therefore,  Avarrants  the  expression 
of  a  favorable  prognosis.     But  the  statements  of  this  Avriter  are  not  in 


o 


Q()U  ASIATIC  CHOLERA. 

accordance  with  what  other  authors  have  found,  and  should  not  be  too 
implicity  rehed  upon.  It  is  much  safer  to  regard  every  attack  of  diarrhoea 
Avith  suspicion  during  the  prevalence  of  cholera,  whether  vomiting  occurs 
or  not,  and  to  give  a  favorable  prognosis  only  when  it  readily  responds 
to  treatment. 

The  varying  severity  of  the  disturbances  of  circulation  often  affords 
some  clue  to  the  direction  in  which  matters  are  tending.  Steadily  increasing 
feebleness  of  peripheral  pulsation,  culminating  in  complete  suppression 
of  the  radical  pulse,  is  very  ominous.  If  the  larger  arteries  no  longer 
reveal  pulsation,  death  is  almost  certain.  Other  grave  symptoms  consist 
in  the  fading  away  of  the  apex  beat,  and  Avith  it  the  second  sound,  the 
occurrence  of  blowing  murmurs,  and  the  development  of  pericardial  friction 
sounds.  Dyspnoea,  an  icy  coldness,  and  deep  cyanosis  are  rarely  wanting 
to  still  further  indicate  the  approach  of  death,  when  this  stage  of  the  dis- 
ease has  been  reached. 

The  return  of  pulsation  after  its  complete  interruption  is  a  favorable 
sign  only  when  other  symptoms  of  beginning  reaction  accompany  it. 

Whenever  a  rapid  and  decided  sinking  of  the  temperature  occurs,  we 
may  look  for  a  grave  or  fatal  attack.  Gradual  reduction  of  the  body-heat 
denotes  a  milder  and  more  protracted  affection. 

Macnamara  believes  that  if  the  external  temperature  of  the  body 
"  does  not  sink  below  95°  F.,  the  respiration  not  rising  beyond  25°,  or  the 
pulse  iTpward  of  100,  we  may  safely  conclude  that  our  patient  has  a  very 
good  chance  of  recover}-.  Probably  85  per  cent,  of  such  cases  get  Avell.'"' 
But  "  if  the  temperature  of  the  patient's  body  rapidly  falls  to  93°  or  94°, 
and  remains  at  that  point,  the  respiration  rising  in  proportion  and  the 
pulse  becoming  imperceptible,  our  patient  is  in  extreme  danger,  the  more 
so  as  these  symptoms  have  been  rapidly  induced.-" 

After  a  patient  has  once  passed  into  profound  collapse,  he  may  be 
pronounced  out  of  immediate  danger  only  when  all  the  symptoms  already 
described  as  characterizing  that  condition  have  receded.  In  other  words 
vomiting  and  jDurging  must  stop,  pulsation  must  be  reestablished,  cyanosis 
vanish,  warmth  return,  and  breathing  become  free  and  easy.  A  failure 
in  any  of  these  respects  indicates  the  continuance  of  danger. 

Much  sweating,  except  during  reaction,  is  a  bad  sign.  The  breaking 
out  of  cold,  viscid  sweat  in  patches  here  and  there,  is  more  unfavorable 
than  a  uniformly  distributed  or  relatively  warm  perspiration. 

The  suppression  of  urine  is  generally  a  bad  sign.  On  the  other  hand 
even  in  seemingly  hopeless  cases,  the  exceptional  continuance  of  the  renal 
functions  may  be  the  one  favorable  symptom  on  which  the  faint  possibility 
of  a  rally  still  rests. 

Muscular  spasms  may  become  grave  prognostic  signs,  not  on  account 
of  their  intensity  or  painf ulness,  but  because  they  affect  many  groups  of 
muscles,  and  especially  whe]i  they  attack  the  trunk  rather  than  the  ex- 
tremities. Still,  as  cramps  are  not  peculiar  to  cholera,  they  are  of  com- 
paratively slight  importajuce  in  deciding  or  influencing  prognosis. 

In  regard  to  manifestations  on  the  part  of  the  nervous  system, 
([uietude,  indifference,  apathy,  somnolence,  and  especially  sojjor,  are 
always  more  to  be  dreaded  than  restlessness,  watchful  activity,  sleepless- 
ness and  even  great  anxiety. 

Prognosis  during  the  Period  of  Reaction. — In  pronounced  chol- 
era Avhen  the  patient  has  not  quickly  succumbed  to  the  severity  of  the  dis- 
ease he  is  by  no  means  out  of  danger.     It  is  impossible  to  foretell  from  the 


PROGNOSIS  IN  THE  TYPHOID  CONDITION.  309 

character  of  his  symptoms  during  the  acuteness  of  tlie  attack,  whether  a 
speedy  reaction  or  a  slow  one  is  to  follow,  whether  relapses  are  not  in  store 
for  him,  and  finally  whether  grave  complications  may  not  be  followed 
by  equally  grave  sequela?. 

Oscillations  beween  natural  warmth  and  previous  coldness,  the  appear- 
ance or  persistence  of  viscid  sweat,  the  continuance  of  intestinal  transu- 
dation without  immediate  re-absorption,  are  all  so  many  evil  j^rognostic 
signs,  even  after  reaction  has  been  fairly  established. 

On  the  other  hand,  the  return  of  a  natural  facial  expression,  the 
breaking  out  of  a  uniformly  distributed  warm  perspiration,  the  rapid 
absorption  of  intestinal  fluid,  are  decidedly  favorable  signs.  The  disap- 
pearance of  nervous  manifestations,  taken  in  conjunction  with  the  symp- 
toms just  mentioned,  is  additionally  favorable  to  a  good  prognosis,  since 
a  typhoid  exitus  is  thus  rendered  improbable. 

Concerning  the  importance  of  the  renal  secretion  in  the  period  of  re- 
action, enough  has  been  said  under  Symptomatology  to  make  a  further 
discussion  here  seem  unnecessary.  If  sufficient  healthy  iirine  does  not 
ajopear  soon  after  reaction  is  well  under  way,  a  bad  prognosis  will  have  to 
be  given,  for  ura^mic  symptoms  may  then  be  expected  at  any  moment,  or 
a  fatal  typhoid  is  apt  to  be  inaugurated.  If  the  voided  urine  contains 
much  albumen,  a  small  proportion  of  urea,  and  but  little  sodium  chloride, 
besides  having  a  low  specific  gravity,  the  cholera-typhoid  is  prognostically 
almost  certain.  But  the  opposite  signs  may  be  taken  as  indicating  a  fa- 
vorable turn.  Yet  again  it  must  be  insisted  upon  that,  even  Avhen  this 
favorable  turn  at  so  late  a  period  has  occurred,  joy  and  congratulations 
may  be  turned  once  more  to  sorrow  and  despair  by  a  return  of  former 
symptoms  that  will  now  surely  carry  the  patient  to  his  grave. 

A  rather  unfrequent  complication  incident  to  the  stage  of  reaction,  is 
mentioned  by  ^lacnamara.  It  is  the  formation  of  a  heart-clot  in  the  right 
cavities  usually  extending  into  the  pulmonary  artery  and  its  larger  branches. 
It  appears  to  be  more  common  among  natives  of  India  than  among  Eu- 
ropeans. The  symptoms  are  thus  described  by  the  author  cited:  "The 
patient  seems  to  be  doing  well,  when  suddenly  difficulty  of  breathing 
comes  on,  followed  by  collapse  and  death." 

Prognosis  in  the  Typhoid  Condition  depends  much  more  exclusive- 
ly upon  the  character  and  amount  of  urine  secreted  than  in  the  stage  of 
reaction.  There  may  be  complete  urinary  suppression  early  in  the  develop- 
ment of  the  cholera-typhoid,  and  yet  a  return  of  the  flow  with  an  increas- 
ing tendency  to  normal  renal  activity  will  jiistify  a  favorable  prognosis. 
When,  however,  the  kidneys  are  "  fickle,"  giving  now  promise  of  repair, 
and  again  destroying  that  promise  by  a  cessation  of  function,  the  prognosis 
is  bad. 

Drasche  has  tersely  said,  "  Typhoid  Avith  urine  is  more  favorable  than 
typhoid  without  urine;"  and  there  is  much  truth  in  this  dictum. 

The  appearance  of  well-marked  cholera  exanthem  in  the  typhoid  state  is, 
if  anything,  a  good  omen.  But  the  visible  deposition  of  urea  upon  the  sur- 
face of  the  integument  is  a  bad  one.  The  appearance  of  bloody  stools 
may  be  regarded  as  a  fatal  sign.  If  a  patient  has  had  the  good  fortune  to 
escape  the  8cylla  of  an  attack  of  cholera,  as  well  as  the  Charybdis  of  re- 
action and  typhoid,  smooth  waters  are  at  length  encountered.  For  ex- 
perience has  amply  shown  that  death  from  any  later  complications  and 
sequelae  is  exceptional,  and  one  feels  tempted  to  add  avoidable.  Judicious 
management  with  the  intelligent  cooperation  of  the  patient  in  the  vast 


310  ASIATIC  CHOLERA. 

majority  of  cases  ought  to  land  him  safely  on  the  grateful  shores  of  final 
recovery.  From  the  foregoing  it  Avill  readily  be  seen  that  the  prognostic 
signs  of  a  fatal  issue  are  far  more  numerous,  clear  and  reliable  than  those 
denoting  the  opposite.  This  unfortunate  circumstance  belongs  to  tlie 
nature  of  the  disease,  and  cannot  be  justly  construed  as  a  reproach  to 
medical  skill  and  learning.  An  apparently  faA'orable  sign  is  much  more 
apt  to  mislead  the  unwary  or  inexperienced,  by  being  made  too  much  of, 
than  that  a  fatal  prognosis  is  hapi^ily  put  to  naiight  by  an  unexpected  turn 
in  the  condition  of  the  patient.  Pessimistic  forethought  is  scarcely  any- 
where more  applicable  than  in  an  acute  attack  of  epidemic  cholera. 


THE  METHODS  OF  BACTERIOSCOPY.  3]^  J 


CHAPTER  XXXVII. 

ON  THE  METHODS  OF  BACTERIOSCOPY  ^VND  THE  PREPARATION  OF 

PURE  CULTURES. 

The  detection  and  identification  of  the  cliolera-bacillus,  and  indeed  of 
all  micro-organisms,  is  so  entirely  dependent  upon  the  skillful  employment 
of  special  technical  methods,  only  quite  recently  elaborated,  that  a  succinct 
account  of  the  subject  is  here  given.  It  is  now  universally  admitted  that 
Koch's  method,  as  pursued  at  the  Imperial  German  Health  Board,  consti- 
tutes the  most  perfect  one  3^et  devised  for  exact  bacteriological  researches. 

It  is  proper  to  state,  however,  that  the  technique  as  described  by  him 
in  the  first  volume  of  the  "  Mittheilungen  aus  dem  Reichsgesundheitsamt,"' 
published  in  1881,  has,  especially  in  its  application  to  cholera,  undergone 
certain  changes,  mainly  in  the  direction  of  simplification.  And  it  may  bo 
affirmed  without  exaggeration  that,  in  its  present  shape,  this  method  is 
the  most  reliable  one,  by  far,  where  precise  data  concerning  the  biology  of 
the  micro-organisms  in  question  are  to  be  obtained. 

If  any  argument  were  needed  to  establish  the  importance  of  the  subject 
of  bacterioscop3^  it  might  be  found  in  the  consideration  that  an  adequate 
acquaintance  with  these  modern  methods  of  investigation  is  quite  essential, 
even  to  the  formation  of  a  correct  judgment  concerning  the  present  status 
of  the  cholera  question.  Dr.  Biedert  lias  described  the  improved  methods 
very  clearty, '  and  the  following  account  is  partly  based  on  his  description  r 

It  is  well  to  remember  at  the  outset  that,  all  test  tubes,  flasks,  filters, 
knives,  platinum  wires,  etc. ,  are  always  thoroughly  sterilized  by  overheat- 
ing, immediately  before  being  used.  The  mouth  of  a  test-tube  while  still 
hot  is  plugged  by  sterilized  cotton- avooI.  Double  plugs  are  generally  better 
than  single  ones. 

The  diagi-am  on  the  next  page,  taken  from  Klein,'  shows  a  convenient 
apparatus  for  sterilizing  flasks,  test-tubes,  cotton,  etc. 

The  use  of  fluids  for  purposes  of  artificial  cultures  is  not  advisable  in 
the  study  of  cholera-organisms,  having  been  superseded  by  a  number  of 
solids  that  answer  all  practical  requirements  in  a  very  satisfactory  manner. 
The  principal  substances  now  employed  as  solid  culture  media  are  boiled 

'  More  detailed  descriptions  are  given  by  Prof.  A.  Johne,  and  the  best  exposi- 
tion of  the  entire  subject  of  tlie  metliods  of  bacterial  research  is  found  in  a  work 
just  issued  and  entitled  "Die  Methodender  Bakterien-Forschung,"  von  Dr.  Ferdi- 
nand Hueppe,  Wiesbaden,  1885. 

•^  Deutsche  Medicinal  Zeitung,  Nos.  103  and  104,  1884. 

^  Micro-Organisms  and  Disease.     By  E.  Klein,  M.D.     London,  1884. 


812 


ASIATIC   CHOLERA. 


potatoes,  prepared  gelatine,  and  coagulated  blood  serum.  The  first  two 
of  these,  and  especially  the  second,  are  employed  in  cholera  investigations, 
while  the  third  is  chiefly  used  for  cultures  of  tubercle  bacilli. 


Fig.  9. — Hot  box  for  sterilizing:.  (An  iron  chamber  with  double  wall,  the  inner  chamber  having 
separate  folding  doors.  In  the  inner  chamber  are  placed  the  test-tubes,  cotton-wool,  etc.  Both  sets 
of  doors  are  closed  and  the  apparatus  heated  by  a  large  Fletcher's  burner.  The  thermometer  pas.s- 
ing  out  from  the  inner  chamber  indicates  its  temperature.) 

The  potatoes  arc  first  thoroughly  cleaned  by 
scrubbing-  and  then  placed  for  an  hour  in  a 
solution  of  corrosive  sublimate  (5-1000).  Naxt 
they  are  cooked  in  a  steam  sterilizer. 

The  adjoining  figure  represents  a  convenient 
form  of  steaming  apparatus  of  this  kind  (Lon- 
don Lancet,  September  27,  1884).  It  is  a  cylin- 
drical box  with  a  conical  lid.  An  iron  grating 
{g)  is  fixed  at  a  level  below  the  middle,  and 
serves  to  support  what  has  to  be  steamed.  The 
water  is  poured  in  from  above,  and  heated  ]jy 
a  Bunsen  burner.  The  box  and  lid  are  invested 
by  a  thick  layer  of  felt,  which  reduces  the  loss 
of  heat,  and  so  maintains  the  interior  at  a  uni- 
form temperature.  A  hole  in  the  top  of  the 
lid  admits  a  thermometer,  which  is  held  in 
place  by  cotton-wool.  Having  been  thorough- 
ly sterilized,  the  potatoes  are  now  sliced  with  a 
knife  heated  immediately  before  to  redness,  and 
after  implantation  with  the  suspected  material, 
care  being  taken  that  the  fingers,  although 
washed  in  sublimate  solution,  do  not  come  in 
contact  with  the  cut  surfaces,  they  are  laid 
_  aside  inider  suitable  cover.     The  colonies  grow- 

FiG.  10.— steaming  apparatus  for  ing  ou  the  potatoes  may  be  removed  for  exami- 

steriiizing  potatoes,  etc.  nation  at  any  period  of  their  development. 

To  prepare  blood-serum  as  a  medium  for  cultures  requires  much  more 

care  than  the  simple  sterilization  of  potatoes.     The  blood-serum,  in  order 


STERILIZATION  OF  BLOOD-SERUM. 


to  i^revent  coagulation,  is  prepared  by  heating  it  once  a  day  for  eight 
days  up  to  135°  F/  This  destroys  only  the  bacteria  each  time,  and  not 
the  spores.  But  as  the  latter  become  developed  from  day  to  day  into  bac- 
teria, they  are  in  turn  killed,  and  in  this  way  at  the  expiration  of  eight 
days  the  process  of  sterilization  is  completed. 


Fig.  11.— Receptacles  and  covers  for  potato-cultures. 

In  order  to  solidify  it,  the  serum  is  then  heated  up  to  159°  F.,  not  any 
higher  lest  it  become  turbid,  and  is  so  poured  into  test  tubes  as  to  prevent 
a  broad  sloping  surface  exposed  to  the  air. 

The  accompanying  diagrams  illustrate  Koch's  apparatus  for  the  sterili- 
zation of  blood-serum.  It  consists  of  a  double  cylinder  made  of  sheet 
copper  and  provided  with  a  hollow  lid.  The  cylinder  is  half  filled  with 
water,  the  hollow  lid  likewise  contains  water.  The  lid  has  three  openings 
into  which  thermometers  are  fitted.     One  of  these  shows  the  temperature 


Fig.  12.— Koch's  apparatus  for  the  sterOization  of  blood-serum. 

of  the  water  in  the  lid,  another  that  of  the  air  in  the  cylinder,  and  the 
third  that  of  the  water  in  the  cylinder.  The  manner  of  heating  the  water 
both  in  the  lid  and  in  the  cylinder  appears  from  inspection  of  the  figures. 
As  already  intimated,  however,  an  apparatus  of  this  kind  is  not  essential 
for  the  diagnostic  recognition  of  cholera-bacilli. ' 

For  this  purpose  gelatine  cultures  are  now  quite  generally  emjiloyed, 

'  This  is  reall^^  Tyndall's  metliod  of  sterilization  by  discontinuous  heating-. 
See  his  Essays  on  the  "  Floating  Matter  of  the  Air,"  second  edition,  1883. 

^  J.  F.  Luhme  &  Co.,  Berlin  N.  W.,  Friedriclis.strasse  100,  supply  all  the  uten- 
sils and  apparatus  required  for  the  employment  of  Koch's  metliods. 


314 


ASIATIC  CHOLERA. 


since  they  possess  unmistakable  advantages  over  the  other  media.  To 
prepare  them  the  gelatine  must  be  mixed  with  some  vegetable  infusion, 
or  what  is  preferable,  with  peptonized  meat  broth.  The  present  mode  of 
preparing  the  latter  is  as  follows:  One-quarter  of  a  kilogram  (one-half 
pound)  of  chopped  meat  (lean  beef),  is  placed  in  a  half  litre  (one  pint) 
of  distilled  Avater  and  allowed  to  stand  in  a  cool  place  for  '24  hours.  It 
is  then  strained  through  gauze  and  brought  up  to  400  ccm.  (about  V^ 
ounces),  and  to  it  are  added  2  grm.  (30  grains)  of  salt,  4  grm.  (GO  grains) 
dried  peptone  (peptonum  siccum,  Witte),  and  40  grm.  (600  grains)  pure 
commercial  gelatine.  After  standing  for  half  an  hour  the  mixture  is 
warmed  slightly  until  the  gelatine  is  dissolved,  and  is  then  neutralized 
with  a  saturated  solution  of  carbonate  of  soda,  until  it  will  just  turn  red 
litmus  paper  blue.  It  is  then  carefully  boiled  over  a  water  bath  for  at 
least  an  hour,  until  all  the  albumen  is  separated  and  the  fluid  becomes 
colorless.  A  small  quantity  of  this  filtered  and  heated  in  a  test  tube 
should  give  no  cloud,  or  at  the  most  only  a  very  faint 
one,  for  the  gelatine  must  be  very  clear  and  transpa- 
rent for  use  under  the  microscope.  A  very  faint 
milkiness  may  be  caused  by  heating,  even  when  the 
fluid  is  entirely  free  from  albumen;  this  is  due  to 
the  presence  of  phosphates,  and  disappears  on  cool- 
ing. The  solution  is  then  to  be  filtered  hot.  This 
may  be  done  quite  conveniently  and  speedily  by 
passing  a  Bunsen  burner  rapidly  around  the  funnel 
containing  the  filter  and  thus  keeping  it  hot  until 
the  process  is  completed.  It  must  be  done  carefully 
in  order  to  avoid  breaking  the  glass  funnel.  A  spirit 
lamp  may  be  used  instead  of  the  Bunsen  burner, 
care  being  taken  not  to  spill  the  alcohol  in  the 
rapid  movements  necessary.  A  somewhat  more  ex- 
pensive but  much  better  plan  is  to  provide  one's  self 
with  a  hot- water  filter,  as  shown  in  the  accompanying 
diagram. 

The  test  tube  is  noAV  prepared  by  introducing  a 
pledget  of  cotton  a  short  distance  and  heating  over  a  Bunsen  burner 
or  spirit  lamp,  first  the  portion  below  the  plug  and  then  that  above  it. 
The  cotton,  slightly  browned  by  the  heat,  is  finally  seized  with  pre- 
viously heated  forceps  and  drawn  up  to  the  open  end  of  the  tube. 
Tlie  gelatine  broth  is  now  poured  in  until  it  fills  not  quite  a  third 
of  the  test  tube  and,  without  removing  the  plug,  is  boiled  thor- 
oughly on  four  successive  days  in  order  to  insure  perfect  sterilization. 
Care  ^nust  be  observed  during  this  process  not  to  wet  the  cotton 
if  possible.  A  light  cloud  of  phosphates  may  be  formed  at  each 
boiling,  but,  as  before  mentioned,  disiippears  again  on  cooling.  After  a 
few  Aveeks  such  gelatine  becomes  unfit  for  use,  through  evaporation  Avhicli 
takes  place  through  the  plug.  This  may  be  prevented  by  covering  the 
mouth  of  the  test  tube  with  gutta-percha  tissue.  In  this  way  the  gelatine 
may  be  preserved  unchanged  for  a  long  time,  but  it  is  better  to  heat  the 
upper  portion  of  the  tube  containing  the  wadding,  once  in  a  while,  to  make 
sure  that  the  sterility  of  the  solution  is  maintained. 

When  employed  for  plate  cultures  the  gelatine  material  is  poured  out 
in  a  very  thin  layer  on  glass,  and  simply  left  uncovered  if  the  germs  in 
the  atmosphere  aVe  to  be  studied,  or  sprinkled  with  dust  from  the  ground 


Fig.  13.— Hot-water  fil- 
ter for  gelatine  meat-solu- 
tions, etc. 


THE  PREPAEATION  OF  PURE  CULTURES. 


315 


if  that  be  the  subject  of  investigation.  When  other  matters  containing 
microbes  are  to  be  examined  they  are  mixed  Avith  the  gelatine  before  it 
is  poured  from  the  test-tube.  The  gelatine  is  first  liquified  b)^  careful 
Avarming,  and  then,  for  the  sake  of  greater  security,  is  boiled  once  more  and 
afterward  allowed  to  cool  to  about  the  temperature  of  the  body,  in  order 
that  the  microbes  about  to  be  studied  may  not  be  injured  by  too  great 
heat.  A  small  drop  or  a  minute  piece  of  the  matter  to  be  subjected  to  the 
culture  experiments — for  example  a  bit  of  suspected  cholera  dejection — is 
takcTi  up  by  a  loop  of  previously  heated  platinum  wire,  and  put  into  the 
fluid  held  inclined  in  the  test  tube,  then  after  replacing  the  cotton  plug 
the  tube  is  inclined  from  side  to  side  in  order  to  diffuse  the  material  thor- 
oughly through  the  fluid  gelatine. 

But  the  gelatine  is  not  yet  ready  for  the  plate  cultures.  For  after 
one  or  several  days  the  numerous  bacterial  forms  contained  in  the  material 
enq^loyed  (suspected  intestinal  matter,  for  example),  will  have  increased 
to  such  a  degree  that  it  becomes  impossible  to  isolate  each  or  any  particular 
kind.  It  is  necessary,  therefore,  to  still  further  separate  the  different 
bacterial  groups  by  dilution.  To  this  end,  as  soon  as  the  material  is  well 
diffused  tlirough  the  gelatine  in  the  first  test  tube,  three  drops  are  taken 
out  by  the  looped  platinum  wire  and  put  into  a  second  tube;  then  after 
thorough  admixture  three  drops  are  taken  from  this  in  the  same  way  and 
placed  in  a  third  tube.  The  contents  of  the  three  tubes  are  then  poured 
out  on  glass  plates.  The  gelatine  from  the  second  tube  sometimes  answers 
the  purpose,  but  that  from  the  third  is  generally  found  to  contain  the 
microbes  in  just  about  sufficient  number. 


m   «-      \ 

A 

^^^  ^/ « 

.=»_=_«, 

Fig.  14.— Excavated  glass-slide;  .4,  from  above;  i?,  in  cross  section;  «,  the  moist-chamber;  Z>,  the 
cover-slip;  c,  the  drop  of  fluid  containing  the  bacteria  to  be  studied. 

At  the  end  of  from  one  to  four  days  the  bacterial  colonies  may  be 
seen  with  the  naked  eye  as  little  points  in  the  gelatine,  and  if  they  seem 
to  be  numerous  enough  and  yet  discrete,  the  plates  are  to  be  examined 
under  the  microscope  with  a  low  magnifying  power,  of  100  diameters  or 
so,  in  order  to  determine  the  condition  of  the  gelatine  and  to  see  that 
the  particular  colony  sought  for  is  isolated  and  that  no  other  lies  above 
or  below  it,  or  too  near  alongside.  This  particular  colony  having  been 
accurately  located,  may  usually  be  picked  out  from  the  gelatine  without 
the  aid  of  the  microscope,  by  means  of  a  previously  heated  platinum  needle. 
Biit  the  plate  should  always  again  be  examined  microscopically  to  make 
sure  that  the  colony  sought  for  and  no  other  one  has  been  touched  in  the 
process  of  removal. 

In  case  the  colony  is  too  small  or  lies  too  near  another  to  allow  of 
separation,  when  viewed  with  the  naked  eye  alone,  the  oj^eration  must  be 


316  ASIATIC   CHOLERA. 

done  under  the  microscope;  a  little  practice  renders  this  easy  of  accom- 
plishment. 

The  organisms  thus  obtained  with  every  guarantee  of  perfect  piirity 
may  now  be  studied  in  a  variety  of  ways.  "When  they  are  to  be  used  as 
stained  preparations  a  drop  of  water  is  first  brought  on  a  cover  glass  and 
impregnated  with  the  mass;  this  is  then  dried  in  the  air  or  Avith  gentle 
heat,  drawn  three  times  through  the  flame,  stained  Avith  an  aqueous  solu- 
tion of  f  uchsine,  rinsed  with  water  and  placed  under  the  microscope.  The 
microbes  must  be  all  of  the  same  kind,  and  when  there  are  spores  they 
should  be  little  or  not  at  all  stained. 

The  bacterial  colonies  may  also  be  examined  in  excavated  slides,  either 
in  water  to  study  their  movements,  or  in  meat  broth  to  observe  their  de- 
velopment. The  latter  is  prepared  in  exactly  the  same  way  as  the  gelatine 
culture  medium  except  that  no  gelatine  is  added.  A  minute  particle 
is  placed  with  a  drop  of  water  or  broth  on  a  cover  glass  and  then  put  over 
the  hollow  in  the  slide.  The  edges  of  the  excavation  are  greased  with  a 
little  vaseline  so  that  with  the  cover  glass  it  forms  a  moist  chamber  pro- 
tected from  the  air.  In  water  the  movements  of  the  micro-organisms  may 
be  readily  observed,  and  in  the  broth  we  may  watch  the  microbes  growing 
in  a  pure  culture.  In  order  to  insure  the  purity  of  the  culture,  the  cover 
glass  should  of  course  be  previously  sterilized  by  passing  it  through  the 


If: 


YiG.  15. A  glass  cell  for  observing  under  the  microscope  the  progress  of  gi'owth  of  micro- 

organisins.  A,  glass  slide;  B,  cover  glass;  C,  glass  ring  forming  the  wall  of  the  chamber;  P,  drop 
of  noui-ishing  material  in  which  the  micro-organisms  grow.    (Klein.) 

flame  of  a  spirit  lamp.  Since  the  preparation  is  unstained  a  diaphragm 
with  a  small  aperture  must  be  used.  The  Abbe  condenser,  which  is  used 
for  stained  preparations  without  the  diaphragm,  may  remain.  But  a 
better  kind  of  glass  cell  than  the  "one  just  described  is  made  by  cementing 
a  glass  ring  about  three-fourths  of  an  inch  in  diameter  and  about  one 
eighth  of  an  inch  high,  on  to  an  ordinary  glass  slide.  By  placing  the  pre- 
viously heated  cover  glass  over  this  ring,  the  upper  edge  of  Avhich  is 
smeared  with  a  little  vaseline,  a  very  convenient  chamber  is  secured.  The 
bottom  of  the  cell  receives  a  little  drop  of  Avater  in  order  to  insure  the 
necessary  degree  of  moisture  in  the  cell.  A  glass  cell  of  this  kind  may  be 
kept  on  a  warm  stage,  for  any  length  of  time. 

Another  proving  may  be  made  by  transplantation  of  the  material  obtained 
in  the  manner  above  described  to  a  sliced  potato.  The  mode  of  growth  on 
this  medium  furnishes  a  ncAv  biological  characteristic  of  the  particular  mi- 
crobe. Potatoes  may  also  be  used  to  obtain  pure  cultures  from  mixed  ma- 
terial. The  latter  is  spread  over  a  Avide  area  of  the  cut  surface,  then  a  little 
is  taken  from  this  and  smeared  over  a  second  slice,  and  again  some  from 
this  to  be  spread  over  a  third  piece,  a  method  Avhich  is  seen  to  be  analo- 
gous to  the  dilution  practiced  in  plate  cultures.     This  is,  hoAvever,  not  to 


GLASS-PLATE  CULTUEES. 


317 


be  compared,  as  regards  the  certainty  of  having  really  obtained  a  pure 
culture,  with  the  gelatine  method,  since  it  is  impossible  to  verify  results  at 
at  every  stage  with  the  microscope. 

The  necessity  of  a  microscopical  control  of  all  cultures  is  a  point  to  be 
insisted  on,  and  one  that  is  not  generally  appreciated.  Trusting  merely 
to  naked-eye  appearances  is  liable  to  lead  to  fatal  errors  in  seeking  after 
pure  cultures. 

Any  number  of  pure  cultures  can  now  be  easily  made  by  putting  a 
particle  of  the  colony  removed  as  above  described  from  the  plate  cultures 
by  means  of  a  platinum  needle,  into  the  sterilized  gelatine  in  a  test  tube. 
The  transplantation  is  effected  while  the  tube  is  held  inclined  at  an  angle 
or  reversed,  and  immediately  it  is  accomplished  the  cotton  plug 
is  replaced.  If  the  operation  have  been  successfully  done  the 
microbes  will  remain  isolated  and  unmixed  during  their  entire 
life  in  the  new  soil.  According  to  Van  Ermengem '  cholera 
bacilli  Avill  live  six  or  se^^en  weeks  in  the  gelatine  media  in  test 
tubes. 

A  practical  point  concerning  the  technique  of  plate  cul- 
tures may  here  be  mentioned.  In  the  laboratory  of  the  Impe- 
rial Board  of  Health,  at  Berlin,  the  glass  plates  used  for  this 
purpose  are  about  G  inches  long  and  4  inches  wide;  and  they 
are  just  suited  to  receive  the  gelatine  contained  in  one  test 
tube.  But  in  order  to  use  plates  of  this  size  the  microscope 
must  be  provided  with  a  very  large  stage.  When  the  stage  is 
not  of  sufficient  size  it  is  better  to  use  smaller  plates.  Bie- 
dert  makes  them  2  inches  wide  and  4  inches  long,  thus  using 
two  of  them  to  receive  the  contents  of  a  single  tube.  Another 
advantage  in  using  two  smaller  plates  is  that  while  examining 
one,  the  second  may  be  kept  under  cover  protected  from  the  air 
and  other  sources  of  contamination.  Before  being  used  these  Fig.  ic- 
plates  must  be  sterilized,  at  least  on  one  side,  by  passing  them  ino-uiating 
through  a  flame  that  does  not  smoke;  they  are  then  laid  aside  l^^  ^^^''^' 
with  the  heated  side  uppermost  and  covered  at  once  with  a  rial  in  a 
Avatch  glass  or  a  plate,  and  should  not  again  be  touched  on  the  ^^^t-tube. 
sterilized  side.  Three  pairs  of  the  small  plates  being  now  ready,  the 
gelatine  in  three  tubes  is  impregnated  with  the  suspected  material,  as 
above  described,  and  then  being  allowed  to  cool  until  it  is  just  about 
to  stiffen,  is  poured  out  on  the  plates.  Some  little  experience  is 
necessary  to  determine  just  the  proper  time  for  doing  this.  By  means 
of  a  sterilized  glass  rod  the  gelatine  is  now  spread  rapidly  and  evenly 
over  the  plates,  covering  their  entire  surface,  except  for  a  space  about 
one-fifth  of  an  inch  wide  at  the  edges.  The  plates  of  course  must  lie 
horizontally,  and  are  covered  again  at  once  until  the  gelatine  is  firmly  set. 
The  culture  is  noAv  left  to  grow  in  a  moist  chamber.  If  a  Avatch  glass  is 
used,  a  piece  of  moistened  blotting  paper  may  be  put  in  the  glass  trough 
in  Avhich  the  plates  are  set.  Or  the  glass-plates  am  be  laid  on  moistened 
blotting  paper  between  two  ordinary  dinner  plates. 

A  very  convenient  apparatus  for  maintaining  glass-plates,  slides,  etc,  in 
a  horizontal  position,  and  at  the  same  time  subjecting  them  to  the  action 


'  Contribution  a  TEtude  du  Microbe  du  Cholera.  Communication  made  to  the 
Belgium  Microscopical  Society  at  its  meeting  of  Oct.  26,  1884.  Reported  also  in 
the  Deutsche  Medical  Zeitung-,  vol.  ii.,  1884,  p.  498. 


318  ASIATIC  CHOLERA. 

of  cold  in  order  that  the  gelatine  may  qnickly  solidify,  is  represented  in 
the  adjoining  figure. 

The  glass  plate  g  rests  on  a  triangle  made  of  wood,  and  by  regulating 
the  screws  a  perfectly  horizontal  jjosition  can  be  maintained.  Pounded 
ice  or  snow  can  be  placed  under  the  glass  plate  to  effect  rapid  cooling. 
Moistened  blotting  paper  should  be  placed  in  the  glass  receptacle  before 
it  is  covered. 


Fig.  17.— Apparatus  for  gelatine  glass-plate  cultures.    Hueppe. 

In  the  examination  of  cultures  thus  obtained  from  mucous  flocculi 
taken  from  cholera  dejections,  the  decisive  work  begins  in  24  to  48  hours 
after  the  prejiaration  of  the  plates.  In  examining  now  the  larger  or  smaller 
sunken  points  with  a  low  magnifying  power,  some  of  the  peculiarities 
chara  teristic  of  comma-bacilli  cultures  are  made  manifest.  The  distin- 
guishing features  of  these  bacilli,  when  examined  in  the  various  ways 
above  described,  may  be  briefly  set  forth  as  follows: 

1.  In  plate  cultures  (low  power,  90-100)  a  whitish  spot  with  irregularly 
indented  borders  is  seen.  It  appears  to  be  made  up  of  granules  with  a 
glossy  luster.  In  consequence  of  the  sinking  in  of  this  spot  with  the  for- 
mation of  a  bubble  of  air,  it  seems  to  be  surrounded  by  an  area,  at  first 
shining,  witli  a  reddish,  mother-of-pearl  tint,  and  later  black;  in  the 
center  of  this  lies  the  whitish  glistening  colony.  There  is  later  a  little 
more  marked  but  never  an  extensive  liquefaction  of  the  gelatine. 

2.  In  pure  cultures  in  the  test  tube  there  is  a  funnel-shaped  sinking  in 
of  the  whitish  colony,  with  fluidity  of  the  medium  beloAv  and  the  forma- 
tion of  an  air  bublDle  above.  Fine  white  lines  may  be  seen  extending 
downward.     In  eight  days  there  is  extensive  liquefaction  of  the  gelatine, 

3.  In  broth  cultures  in  hollow  slides,  after  24  hours,  swarms  of  quickly- 
moving  bacilli  are  seen  with  many  long  screw-shaped  spirilla  in  the  center 
of  the  drop.  At  the  edges  beautifvd  commas  lying  closely  crowded  together 
are  readily  detected. 

4.  In  stained  specimens  are  seen  the  little  curved  rods  of  equal  width 
throughout,  about  half  as  long  and  of  the  same  thickness  as  tubercle 
bacilli.  They  are  often  joined  together  in  S  or  U  shapes.  When  the 
preparations  are  made  from  cultures  in  hollow  slides  the  bacilli  often  form 
beautiful  long  spirilla,  which  are  thicker  and  have  less  pronounced  curves 
than  the  salivary  sjjirilla. 

5.  No  spores  are  ever  found  in  the  stained  prejiarations,  no  matter  at 
what  period  of  the  culture  they  are  examined. 

6.  Another  characteristic  of  the  cholera  commas  is  their  ra2)id  death 
when  dried.  Biedert  states  that  he  found  a  culture  in  a  hollow  slide  dead 
ten  minutes  after  drying,  and  it  is  the  rule  that  no  more  livin  gbecilli  are 
to  be  met  with  longer  than  one  or  two  hours  after  thorough  drying. 

7.  The  growth  of  these  micro-organisms  is  retarded  or  arrested  by 
moderately  low  temperatures  or  in  acid  culture  media.      (Van  Ermengem  ' 

"  '  Loe.  (.it.  ' 


THE  COMMA-BACILLUS  A  DISTINCT  SPECIES.  3^9 

lias,  however,  observed  them  develop,  though  very  slowly,  in  temperatures 
between  46°  and  58^^  F.) 

8.  They  are  seen  to  grow  under  a  thin,  dark,  yellowish  brown  covering 
in  potato  cultures  in  an  incubator;  but  this  does  not  occur  at  ordinary 
temperatures. 

These  several  characteristics  present  the  sharply  defined  picture  of  a 
special  organism.  But  they  are  only  observed  in  pure  cultures,  except 
those  described  under  the  fourth  heading,  and  even  these  are  seen  most 
clearly  in  pure  cultures  alone.  This  imi^ortant  point  is  now  universally 
conceded  by  those  most  competent  to  judge.  And  even  Klein,  who  as 
has  been  shown,  opposes  Koch  in  almost  every  particular,  is  compelled  to 
admit  that  the  comma-bacilli  of  cholera  constitute  a  distinct  species.  In 
his  most  recent  publication,  entitled  "  Some  Eemarks  on  the  Present  State 
of  our  Knowledge  of  the  Comma-bacilli  of  Koch,"  he  says:' 

"■'  As  far  as  the  observations  hitherto  go.  there  is  no  doubt  whatever, 
that  the  comma-bacilli  of  Koch  are  a  distinct  species,  characterized  by 
their  behavior  in  cultivations  in  gelatine-material,  and  that  this  distinct 
species  occurs  in  the  intestine  of  human  beings  suffering  from  cholera; 
but  whether  they  occur  here  in  numbers  in  consequence  of  the  peculiar 
condition  of  the  intestine  in  this  disease,  or  whether  they  are  the  cause  of 
it — that  is  to  say,  whether  post  hoc  or  irropter  hoc — is,  I  maintain,  an  open 
question,  Avhich  Koch  has  not  proved,  and  which  he  has  not  attempted  to 
prove.  And  this  question  will  remain  unanswered  until  the  examination 
of  the  intestine,  under  precisely  similar  but  not  choleraic  conditions  (that 
is,  distension  of  tbe  intestine,  and  exudation  into  it  of  clear  fluid  and  mucus 
flakes)  is  made,  and  until  it  is  found  that  these  same  comma-bacilli  are 
always  absent. "  It  ap])ears, therefore, that  Klein  now  disputes  the  diagnostic 
significance  of  the  detection  of  Koch's  commas  in  a  rather  conditional  and 
half-hearted  way,  and  not  in  a  manner  to  convince  one  that  he  feels  sure 
that  he  is  right  and  Koch  is  wrong.  Doubtless  the  last  word  in  the  matter 
has  not  yet  been  spoken. 

Meantime  it  may  be  interesting  to  know  that,  as  stated  by  Dr.  Heron, - 
Koch  is  prepared  to  start  at  short  notice,  with  a  band  of  competent  as- 
sistants, to  examine  into  and  ascertain  by  this  method  the  exact  nature  of 
any  case  of  supposed  cholera  wnicli  might  occur  in  Germany.  The  in- 
vestigation would  take  not  more  than  a  few  days,  and  during  that  time 
the  suspected  person  or  persons  could  be  most  rigidly  isolated.  There 
is  reason  to  hope,  therefore,  that  Dr.  Koch's  great  influence  will  be  thrown 
on  the  side  of  medical  inspection,  against  quarantine. 

'  The  British  Medical  Journal,  April  4,  1885. 

-  Editorial  on  the  Etiology  and  Diagnosis  of  Cholera,  publislied  in  the  Bi'itish 
Medical  Journal,  April  4,  1885. 


PART   SIXTH. 


THE  PREVENTION  OF  CHOLERA. 


SEOTIOIvr    I. 
THE  DESTRUCTION  OF  CHOLERA  GERMS. 

BY 

GEORGE  M.  STERNBERG,  M.D., 

SURGEON,  U.   S.   A. 


THE  DESTRUCTION  OF   CHOLERA  GERMS.  325 


CHAPTER  XXXVIII. 

THE  DESTRUCTION  OF  CHOLERA  GERMS— EXTERNAL  AND 
INTERNAL  DISINFECTION. 

General  Remarks. — The  -writer  of  the  present  chapter,  while  ad- 
mitting that  it  is  not  definitively  proved  that  the  "comma-bacillus"  of 
Koch  is  the  veritable  germ  of  cholera,  considers  the  experimental  evi- 
dence in  favor  of  this  view  to  be  of  such  a  nature  as  to  make  it  highly- 
probable  that  such  is  the  case. 

That  a  micro-organism  of  some  kind  is  concerned  in  the  etiology  of 
cholera  can  scarcely  be  doubted.  A  multitude  of  facts  relating  to  the 
origin  and  extension  of  the  disease,  to  the  conditions  governing  its  epidemic 
prevalence,  its  modes  of  transmission,  etc.,  gives  support  to  this  views. 

It  is  certain  that  something  contained  in  the  dejections  of  cholera 
patients  is  competent  to  give  rise  to  the  disease  in  others,  either  directly,  as 
when  washerwomen  contract  the  disease  from  handling  soiled  clothing, 
or  by  the  establishing  of  new  epidemic  foci  as  a  result  of  the  external  de- 
velopment of  this  ''something,"  when  conditions  are  favor ubU  and  the 
alvine  discharges  of  cholera  patients  are  scattered  broadcast  Avithout  pre- 
viously undergoing  disinfection. 

It  is  extremely  probable  that  the  spirillum,  so-called  ''  comma-bacil- 
lus," which  has  been  demonstrated  by  the  researches  of  Koch  and  others 
to  be  constantly  present  in  the  intestinal  contents  of  the  victims  of  cholera, 
and  in  the  rice-water  discharges  which  characterize  this  disease  during  life, 
is  causative  of  cholera.  In  what  follows  we  shall  keep  this  probability  in 
view,  and  our  practical  directions  relating  to  disinfection  will  have  refer- 
ence to  the  destruction  of  a  germ  which  has  no  resting  stage,  i.e.,  which 
does  not  form  endogenous  spores. 

In  advance  of  the  exact  knowledge  of  this  particular  organism  which 
we  owe  to  the  researches  of  Koch,  we  had  indirect  evidence  that  the  cholera 
germ  must  not  form  resting  spores,  such  as  give  to  known  bacilli  their 
gi-eat  power  of  resistance  to  chemical  reagents  and  to  high  temperatures;  for 
in  this  case  it  would  be  difficult  to  account  for  the  fact  that  this  disease  does 
not  obtain  a  lodgment  in  regions  outside  of  the  area  in  which  it  is  indigenous, 
and  that  after  a  brief  period  of  epidemic  prevalence  it  disappears.  After 
having  been  introduced  into  our  own  country,  for  example,  it  prevails  for 
a  certain  length  of  time,  then  dies  out,  and  does  not  return  except  in  con- 
sequence of  a  fresh  importation. 

With  this  brief  introduction,  we  proceed  to  consider  the  means  at  our 
command  for  tlie  destruction  of  cliolera  germs  external  to  the  bodies  of  in- 
fected individuals — with  reference  to  prophylaxis,  and  the  therapeutic 


326  ASIATIC   CHOLERA. 

possibilities  suggested  by  our  knowledge  of  the  germicide  or  restraining 
power  of  various  chemical  agents  upon  micro-organisms  of  this  class. 

External  Disinfection. — It  is  evidently  of  paramount  importance, 
in  our  efforts  to  restrict  the  extension  of  cholera,  that  all  germs  be  de- 
stroyed before  they  fall  upon  that  favorable  soil  for  tlieir  development 
which  is  found  in  sewers,  cesspools,  and  foul  places  generally.  In  the 
sick  room  we  have  these  infinitesimal  enemies  'at  an  advantage,  for  we 
know  where  to  find  them  and  how  to  kill  them.  Not  to  destroy  them 
under  these  circumstances,  and  with  a  full  knowledge  of  their  malignant 
potency,  would  be  nothing  less  than  criminal  negligence. 

Recent  experiments  have  demonstrated  that  many  of  the  agents  which 
have  heretofore  been  relied  upon  as  disinfectants  are  completely  untrust- 
worthy when  the  object  in  view  is  the  complete  destruction  of  disease 
germs.  Popularly  an  agent  which  destroys  or  masks  offensive  odors  is 
called  a  disinfectant;  and  many  physicians  and  chemists  still  regard  any 
agent  which  arrests  putrefaction,  antiseptic,  or  which  destroys  putrefactive 
products,  as  a  disinfectant.  From  our  point  of  view,  a  disinfectant  is  an 
agent  which  destroys  the  infecting  power  of  infectious  material.  A  disin- 
fection consists  in  the  complete  accomplishment  of  this  object.  An  agent, 
therefore,  which  restricts  the  development  of  disease  germs  without  de- 
stroying their  vitality  and  power  to  develop  subsequently  in  the  presence 
of  favorable  conditions,  is  not  a  disinfectant.  When  filth  cannot  be  en- 
tirely destroyed  or  removed  from  the  vicinity  of  liuman  habitations,  there 
can  be  no  doubt  as  to  the  desirability  of  treating  it  with  chemical  agents 
which  arrest  putrefactive  decomposition,  and  which  at  the  same  time  make 
it  unfavorable  soil  for  the  development  of  disease  germs.  This  is  especially 
true  during  the  prevalence  of  epidemics.  We  therefore  favor  the  liberal 
use  of  antiseptics  when  the  complete  removal  or  destruction  of  putresciljle 
material  is  impracticable.  For  this  purpose  the  metallic  sulphates  and 
chlorides  now  extensively  used  are  to  be  recommended.  On  the  score  of 
economy  and  efficiency  the  commercial  sulphate  of  iron  is  perhaps  entitled 
to  the  first  place.  But  when  the  object  is  to  disinfect,  i.  e. ,  to  destroy  the 
developing  power  of  disease  germs,  these  agents  are  entirely  unreliable. 
My  experiments  published  in  the  American  Journal  of  the  Medical  Sciences 
in  April,  1883,  show  thut  pure  sulphate  of  iron  in  saturated  solution  does 
not  kill  micrococci  or  bacilli  without  spores;  and  sulphate  of  zinc  in  the 
proportion  of  20  per  cent,  failed,  in  two  hours  time,  to  destroy  micrococci 
obtained  from  the  pus  of  an  acute  abscess.  According  to  Arloing,  Cornevin 
and  Thomas,  exposure  for  48  hours  to  a  20  per  cent,  solution  of  sulphate 
of  iron  does  not  destroy  the  virus  of  symptomatic  anthrax,  which  contains 
spores.  Dr.  Duggan  has  recently  tested,  at  my  request,  the  germicide 
power  of  the  sulphate  of  copper,  and  reports  that  a  30  per  cent,  solution 
of  this  salt  added  to  an  equal  quantity  of  ' '  broken  down  "  beef  tea  does 
not  destroy  the  vitality  of  the  contained  organisms  in  two  hours  time.  The 
authors  above  quoted  found  that  48  hours  exposure  to  a  20  per  cent,  solu- 
tion was  successful  in  destroying  the  activity  of  dried  virus  of  symptomatic 
anthrax.  The  exact  germicide  value  of  cupric  sulphate  for  micrococci  and 
bacilli  without  spores  has  not  yet  been  determined;  but  while  it  is  doubtless 
more  potent  than  the  ferric  or  zinc  sulphate,  there  is  no  reason  to  suppose 
that  it  will  be  of  any  great  practical  value  for  disinfection  on  a  large  scale. 
The  metallic  chlorides  have  greater  germicide  potency,  but  this  is  not 
sufficient  to  justify  their  use  as  disinfectants  when  large  masses  of  ma- 
terial are  to  be  dealt  with,  as  in  privy  vaults,  etc.    The  same  may  be  said  of 


EXTERNAL  DISINFECTION.  o,^- 

carbolic  acid  and  of  a  majority  of  the  proprietary  "  disinfectants, "'  so-called, 
which  are  in  the  market.  It  does  not  require  the  application  of  biological 
tests  to  decide  upon  the  comparative  value  of  these  agents  as  deodorizers. 
Any  one  with  a  good  nose  may  judge  of  this  matter,  and  there  is  nothing 
to  be  said  against  the  use  of  any  one  of  them  for  the  jjurpose  mentioned, 
or  for  the  arrest  of  putrefactive  decomposition.  But,  unfortunately,  many 
of  these  agents  have  been  recommended  as  disinfectants  by  physicians  and 
by  chemists,  and  now  enjoy  the  confidence  of  the  public  as  destroyers  of 
disease  germs,  when  the  only  evidence  of  such  supposed  potency  is  that 
obtained  by  the  application  of  the  nose  test.  The  onl}^  reliable  tests  of 
disinfectants  are  those  in  which  the  proof  of  disinfection  consists  in  the 
destruction  of  infective  virulence  as  shown  by  inoculation  experiments,  or 
of  the  vitality  of  disease  germs,  or  of  non-pathogenic  organisms  of  the  same 
class,  as  shown  by  failure  to  grow  in  suitable  culture  media.  Exact  ex- 
periments of  this  nature  have  given  us  a  very  satisfactory  list  of  disinfect- 
ants, and  have  shown  with  sufficient  precision  for  practical  purposes  their 
comparative  value,  and  the  limits  of  their  germicide  power.  Although  no 
experiments  have  yet  been  published  which  relate  directly  to  the  power  of 
these  agents  to  destroy  the  ''  comma-bacillus  "  of  Koch,  it  is  entirely  safe  to 
take  as  a  guide  the  results  obtained  in  experiments  on  similar  organisms, 
pathogenic  or  non-pathogenic,  with  the  simple  precaution  of  keeping  on 
the  safe  side  as  to  the  amount-  of  the  disinfecting  agent  used,  and  the  time 
of  exposure  to  its  action,  in  applying  in  practice  the  data  obtained  by 
carefully  conducted  laboratory  experiments.  This  is  not  the  r»roper  place 
to  give  in  detail  the  experimental  data  Avhicli  form  the  basis  of  the  methods 
of  disinfection  recommended  in  the  present  chapter;  and  those  Avho  desire 
fuller  information  as  regards  the  nature  of  the  biological  tests  employed, 
and  results  attained,  are  referred  to  the  preliminary  reports  of  the  Com- 
mittee on  Disinfectants  of  the  American  Public  Health  Association,  pub- 
lished in  the  ^Medical  Xews,  Philadelphia. ' 

We  shall  consider  here  onh^  those  agents  which  have  been  proved  to 
be  of  practical  value,  and  it  will  be  our  aim  to  indicate  the  circiimstances 
tinder  which  one  or  the  other  may  have  the  preference,  and  the  best 
methods  of  applying  each  in  order  to  accomplish  the  object  in  view. 

Dry  and  Moist  Heat. — All  micro-organisms  not  containing  spores 
are  quickly  destroyed  by  contact  with  water  or  steam  at  a  temperature  of 
212°  Fahr.  We  have  therefore  always  at  hand  an  extremely  simple 
method  of  disinfecting  clothing,  bed-linen,  etc.,  which  has  been  soiled  by 
the  discharges  of  cholera  patients.  It  is  only  necessary  to  put  them  through 
the  ordinary  process  of  washing  in  boiling  water,  or  to  subject  them  in  a 
properly  constructed  chamber  to  the  action  of  steam.  A  considerably 
lower  temperature  than  that  of  boiling  water  is  fatal  to  micrococci  and  to 
bacilli  in  active  growth,  in  the  absence  of  spores;  and  it  is  only  for  the 
purpose  of  keeping  on  the  safe  side,  and  because  it  is  quite  as  easy  in 
practice  to  "  bring  the  water  to  a  boil "  as  to  stop  the  process  at  a  lower 
temperature,  that  we  insist  upon  boiling. 

\Vg  have  already  remarked  that  the  spirillum  of  Koch — his  "  comma- 
bacillus  " — does  not  form  spores,  and  that  even  if  this  proves  not  to  be 
the  true  cholera  microbe,  there  is  reason  to  believe  that  we  have  not  to  deal 

1  The  reports  thus  far  pubhshed  are  upon  Chlorine,  Bromine  and  Iodine  in  the 
number  of  the  Medical  News  dated  January  25th,  1885;  Commercial  Disinfectants, 
Feb.  7;  Mercurial  Chloride,  Feb.  31;  Dry  and  Moist  Heat,  March  14;  Carbolic 
Acid,  March  21;  Sulpliui-  Dioxide,  Max-ch  28;  Disinfectants,  April  18,  1885. 


328 


ASIATIC  CHOLERA. 


with  a  spore-bearing  organism.  If  such  were  the  case  a  temperature 
above  that  of  boiling  Avater  would  be  required,  for  the  spores  of  man}- 
bacilli  resist  this  temperature  for  a  considerable  time.  But  the  most  re- 
sistant spores  known  are  destroyed  in  a  few  minutes  (10)  by  a  temperature 
of  105 'C.  {2'2V  Fahr.),  and  it  is  very  easy  to  attain  this  temperature  by 
means  of  superheated  steam.  It  is  safe  to  say  that  all  known  disease 
germs  would  be  destroyed  almost  instantly  by  contact  with  steam  at  a  tem- 
perature of  110°C.  ("230°  Fahr.),  and  the  most  rigid  exactions  at  ports  of  en- 
try for  the  disinfection  of  clothing  or  merchandize  by  steam  need  not  go 
beyond  this.  Wherever  it  can  be  applied,  disinfection  by  steam  is  unques- 
tionably one  of  the  most  effectual  and  economical  methods  at  our  command. 
Eecent^  experiments,  made  by  the  writer  at  the  request  of  the  Health 
Officer  of  the  Port  of  New  York,  show  that  it  is  even  practicable  to  dis- 
infect rags  in  the  bale,  by  injecting  steam  at  a  high  temperature  into  the 
interior  of  the  bale  through  hollow  metal  screws. 

In  hospitals  and  for  domestic  disinfection  immediate  immersion  of  soiled 
articles  in  boiling  water  should  be  insisted  upon,  unless  it  is  considered 
more  convenient  to  place  these  articles  in  a  cold  solution  of  mercuric 
chloride  until  they  can  be  sent  to  the  wash-house.  Under  no  circum- 
stances should  such  articles  be  sent  out  of  the  house  to  be  washed,  or  laid 
aside  for  a  time,  without  having  been  first  disinfected;  for  it  is  well  known 
that  washerwomen  are  liable  to  contract  cholera  from  handling  such 
clothing,  and  in  this  way  the  disease  may  be  propagated  before  the  meas- 
ures intended  to  restrict  its  extension  are  put  in  force.  Dry  heat  is  far 
less  effective  than  moist,  and  Koch  has  shown  that  certain  spores  will  re- 
sist a  temperature  which  injures  woolen  fabrics  (140°C.).  A  temperature 
of  100°  C.  ("212°  Fahr.)  maintained  for  one  hour  and  a  half  will,  however, 
destroy  bacteria  without  spores.  This  makes  it  practicable  to  disinfect 
woolen  garments  used  by  cholera  patients,  and  other  articles  which  Avould 
be  injured  by  steam  or  by  immersion  in  boiling  water,  by  placing  them  in 
a  properly  constructed  dry  oven.  Every  quarantine  establishment  should 
be  provided  with  such  a  disinfection  chamber,  and  it  will  be  as  well  to  use 
a  someAvhat  higher  temperature  than  that  mentioned.  Exposure  for  one 
hour  to  a  temperature  of  110°C.  would  no  doubt  be  effective  for  articles 
freely  exposed.  But  it  must  be  remembered  that  in  dry  air  the  heat  has 
A'ery"  little  penetrating  power,  and  that  packages  of  any  kind,  or  even 
clothing  loosely  piled  up  in  the  disinfection  chamber,  are  likely  to  escape 
complete  disinfection. 

What  has  already  been  said  as  to  the  disinfecting  power  of  moist  heat 
furnishes  a  precious  indication  for  proph3'laxis  during  the  epidemic  prev- 
alence of  cholera.  Food  or  water  Avhich  has  been  recently  heated  to  the 
boiling  point  will  not  convey  living  cholera  germs  to  the  interior  of  the 
body.  As  it  is  undoubtedly  true  that  a  A'ast  majority  of  the  cases  during 
an  epidemic  result  from  the  ingestion  of  contaminated  drinking  water,  or 
of  food  containing  active  cholera  germs,  it  is  evident  that  individual  and 
domestic  prophylaxis  is  a  comparatively  simple  matter.  If  there  is  the 
slightest  ground  for  suspecting  that  the  water  supply  is  impure,  it  should 
be  boiled.  After  boiling  it  may  be  cooled  by  the  iise  of  good  pond  ice — 
i.e.,  ice  not  manufactured  during  the  summer  months  and  possibly  from 
impure  Avater.  The  boiling  of  milk  shortly  before  it  is  used  is  still  more 
imperatiA'e,  and  cold  dishes  of  meat,  fruit,  or  vegetables,  Avliich  have  been 
set  aside  for  a  time,  should  be  looked  upon  Avith  suspicion. 

Mercuric  Chloride. — Kecent  researches  have  shoAvn  that  corrosive 


DISINFECTION.  399 

sublinifite,  both  on  account  of  efficiency  and  comparative  cheapness,  is  en- 
titled to  a  leading  place  among  those  agents  upon  which  we-  may  rely  as 
disinfectants.  In  a  paper  upon  this  salt,  in  •which  the  writers  own  ex- 
periments are  considered  in  connection  with  those  of  Koch  and  others, 
published  in  the  Medical  ]N"ews  of  Feb.  21st,  1885,  the  following  conclusions 
are  reached: 

"  Mercuric  chloride,  in  aqueous  solution,  in  the  proportion  of  1:10,000, 
is  a  reliable  agent  for  the  destruction  of  micrococci  and  bacilli  in  active 
growth  not  containing  spores;  and  in  the  proportion  of  1:1,000  it  destroys 
the  spores  of  bacilli — provided  that  the  micro-organisms  to  be  destroyed 
are  fairly  exposed  to  its  action  for  a  sufficient  length  of  time. 

"  A  standard  solution  of  1:1,000  may  be  safely  recommended  for  the 
disinfection  of  bedding  and  clothing  which  can  be  washed;  for  Avashing 
the  floors  and  walls  of  infected  apartments;  for  disinfecting  the  hands  and 
instruments  of  surgeons  and  gynecologists;  and  as  a  disinfecting  wash  for 
superficial  wounds  or  mucous  surfaces.  For  continuous  application  to 
wounds,  etc.,  a  solution  of  1:10,000,  or  less,  should  be  effective. 

''A  standard  solution  of  1:500,  Avith  the  same  quantity  of  potassium 
permanganate,  may  be  safely  recommended  for  the  disinfection  of  liquid 
fecal  discharges,  and  other  fluid  material  supposed  to  contain  "disease 
germs,"  provided  the  time  of  exposure  is  not  less  than  two  hours  and  the 
quantity  of  material  to  be  disinfected  is  not  in  excess  of  that  of  the 
standard  solution  used." 

The  recommendation  relating  to  the  disinfection  of  "  liquid  fecal  dis- 
charges "  has  in  view  the  complete  destruction  of  all  contained  organisims, 
including  spores.  A  much  shorter  time  of  exposure  would  doubtless 
suffice  to  destroy  the  "comma-bacillus"  of  Koch,  or  any  other  organism 
in  active  growth.  The  conditions  might  be  modified  with  safety  to  the 
extent  of  reducing  the  time  of  contact  to  ten  or  fifteen  minutes,  if  the 
material  to  be  disinfected  is  thoroughly  mixed  with  the  disinfecting  solu- 
tion. In  the  standard  solution  recommended,  potassium  permanganate  is 
introduced  for  the  purpose  of  giving  color  to  the  disinfectant,  and  also 
because  of  its  value  as  a  deodorizer.  The  want  of  color  or  odor  in  aqueous 
solutions  of  corrosive  sublimate,  and  the  poisonous  nature  of  the  salt, 
might  lead  to  accidents,  especially  in  domestic  use,  on  account  of  its  being 
mistaken  for  Avater.  The  addition  of  the  permanganate  obviates  this  ob- 
jection, and  serves  a  useful  purpose  as  well  in  neutralizing  temporarily 
any  unpleasant  odor.  As  the  permanganate  is  quickly  decomposed  by 
contact  Avith  organic  matter,  its  deodorizing  power  is  only  exercised  for  a 
brief  time,  and  in  the  proportion  recommended  its  germicide  A'alue  is 
hardly  to  be  considered. 

Taking  the  retail  price  of  these  salts  as  given  in  a  recent  copy  of  the 
American  Druggist,  the  cost  of  500  lbs.  of  the  disinfecting  fluid  recom- 
mended Avould  be: 

Mercuric  chloride  1  lb.  .         .         .         .         .         .         .         .70 

Potassium  permanganate  1  lb.  .         .         .         ,         .         .65 

AVater5001bs 00 


$1.35 


In  making  up  smaller  quantities  it  will  be  well  to  remember  that  the 
amount  of  each  salt  required  to  make  a  1 :  500  solution  is  tAvo  grains  to 
the  litre,  or  about  tAvo  drachms  to  the  gallon. 


330  ASIATIC  CHOLERA. 

For  the  disinfection  of  soiled  clotliing,  l3ed  linen,  and  other  articles 
which  can  be  washed,  a  solution  of  mercuric  chloride  alone,  of  the  strength 
of  1:  5,000,  may  be  used;  this  will  be  about  one  drachm  to  five  gallons  of 
water.  When  circumstances  are  such  that  clothing  cannot  be  immedi- 
ately immersed  in  boiling  water,  upon  being  removed  from  the  patient's 
person  or  bed,  this  will  constitute  the  best  and  cheapest  method  of  disin- 
fecting it  before  sending  it  to  be  washed. 

The  same  solution  may  be  used  to  disinfect  the  surface  of  the  body  of 
the  sick,  the  hands  of  attendants,  and  all  surfaces  which  have  been  soiled 
with  choleraic  discharges. 

In  recommending  that  this  potent  toxic  agent  be  introduced  into  the 
sick-room  as  a  disinfectant,  the  writer  is  aware  that  there  is  a  certain  ele- 
ment of  danger  attending  its  use.  But  this  may  be  guarded  against  by 
due  care,  and  the  dilute  solution  recommended  could  scarcely  be  taken  by 
accident  in  sufficient  quantity  to  produce  death,  as  it  has  a  distinctly  me- 
tallic taste,  and  a  tumblerful  would  hardly  be  a  fatal  dose.  The  danger 
is  certainly  not  greater  than  that  attending  the  use  of  carbolic  acid,  strong 
solutions  of  zinc  chloride,  etc. 

There  is  another  possible  danger,  however,  which  I  consider  it  my  duty 
to  point  out.  The  question  as  to  the  action  of  such  solutions  upon  lead 
pipes  when  the  disinfectant  and  material  to  be  disinfected  are  poured  into 
city  water-closets,  etc.,  is  an  important  one.  This  question  is  being  con- 
sidered by  members  of  the  Clommittee  on  Disinfectants  of  the  American 
Public  Health  Association,  and  their  report  will  doubtless  be  published 
within  a  short  time. 

It  is  hardly  necessary  to  give  the  caution  that  in  practice  solutions  of 
mercuric  chloride  must  be  kept  in  glass,  iron,  or  wooden  vessels.  Recep- 
tacles made  of  any  one  of  the  metals  with  which  mercury  forms  an  amal- 
gam, would  not  only  be  injured  by  contact  with  such  solutions,  but  would 
destroy  their  disinfecting  power  by  decomposing  the  mercuric  chloride. 

The  Hypochlorites  of  Soda  and  of  Lime  occupy  the  first  place 
among  the  oxidizing  disinfectants  on  the  score  of  economy  and  efficiency. 
The  value  of  the  liquor  sod(B  cJiIorinafce  of  the  Pharmacopoeia  depends 
upon  the  amount  of  hypo-chlorite  of  soda  which  it  contains,  and  this  may 
be  conveniently  measured  by  estimating  the  chlorine. '  The  popular  idea, 
however,  that  the  disinfecting  power  is  directly  due  to  the  evolution  of 
chlorine  is  an  error;  and  the  direction  sometimes  given  by  physicians 
to  hang  up  cloths  moistened  with  this  solution  in  the  sick-room,  with  a 
view  to  disinfect  the  atmosphere,  is  based  upon  a  mistaken  conception  of 
its  action.  In  contact  with  organic  matter  the  hypochlorite  is  decomposed 
and  a  large  cjuantity  of  nascent  oxygen  is  liljerated,  which  is  the  active 
agent  in  accomplishing  the  destruction  of  micro-organisms  present.  The 
same  is  true  as  regards  the  chloride  of  lime,  or  bleaching  powder,  which 
owes  its  disinfecting  power  to  the  presence  of  the  hypochlorite  of  lime. 
It  is  a  popular  notion,  which  is  shared  by  many  physicians,  that  the  virtues 
of  chloride  of  lime  as  a  disinfectant  depend  upon  the  gradual  liberation 
of  chlorine,  and  that  when  placed  in  open  vessels  in  the  sick-room,  or  in 
foul  places,  it  will  act  as  an  atmospheric  disinfectant.  Its  value  when  used 
in  this  way  is  extremely  limited,  for  it  is  a  Avell-established  fact  that  the 
presence  of  chlorine,  or  of  any  other  gaseous  disinfectant,  in  the  atmos- 
phere, in  respirable  quantity,  is  quite  inadequate  for  the  destruction  of 

'  See  Dr.  Duggan's  report  in  the  Medical  News,  Feb.  7,  1885,  p.  147. 


DISINFECTION. 


331 


disease  germs.  But  the  hypochlorite  of  lime,  which  is  freely  soluble  in 
water,  and  which  is  present  in  properly  prepared  chloride  of  lime  in  the 
proportion  of  20  to  40  per  cent.,  is  a  most  potent  oxidizing  disinfectant. 
The  hypochlorites  are  not  quite  as  pleasant  to  use  in  the  sick-room  as  the 
odorless  solution  of  mercuric  chloride  which  we  have  recommended,  but, 
on  the  other  hand,  they  are  deodorizers  as  well  as  disinfectants,  and  de- 
stroy noxious  effluvia  as  well  as  germs,  without  being  decidedly  objection- 
able on  account  of  their  odor.  For  the  disinfection  of  excreta  the  hypo- 
chlorites are  to  be  especially  commended  on  account  of  their  prompt  action, 
and  because  they  are  free  from  the  objection  which  suggests  itself  with  ref- 
erence to  the  use  of  mercuric  chloride — viz.,  a  possible  injurious  action 
upon  lead  pipe. 

Labarraque's  solution,  as  found  in  the  market,  differs  considerably  in 
value,  which,  as  stated,  is  estimated  in  terms  of  chlorine.  A  solution 
containing  two  per  cent,  of  available  chlorine  promptly  destroys  germs  of 
all  kinds,  including  spores.  When  diluted  with  four  or  five  parts  of  water, 
for  the  destruction  of  cholera  germs  and  other  organisms  not  containing 
spores,  in  liquid  faeces,  such  a  solution  could  doubtless  be  diluted  with 
safety  to  one  part  in  twenty,  the  time  of  contact  being  two  hours.  But 
as  in  practice  there  will  be  a  disposition  to  make  the  time  of  contact  as 
brief  as  possible,  and  to  empty  the  contents  of  a  vessel  containing  choleraic 
discharges  into  the  nearest  water-closet  or  privy  vault  as  soon  as  possible, 
we  think  it  best  to  insist  upon  the  use  of  comparatively  strong  solutions. 
It  will  be  understood  that  in  all  of  the  practical  directions  given  for  the 
disinfection  of  excreta  the  amount  of  the  disinfecting  solution  used  must 
equal  that  of  the  material  to  be  disinfected.  When  used  in  the  liberal 
manner  which  Ave  advise,  the  question  of  cost  becomes  an  important  one. 
If  this  solution  is  to  be  purchased  from  retail  druggists  in  quart  bottles 
the  cost  of  disinfection  in  a  case  of  cholera  or  of  typhoid  fever  Avill  often 
be  beyond  the  means  of  poor  persons.  But  we  hope  to  see  this  and  other 
reliable  disinfectants  furnished  by  health  officers,  or  by  their  authorized 
agents,  by  the  gallon,  or  barrel,  at  a  price  Avhich  will  bring  them  within 
the  reach  of  all,  or  better  still  at  the  expense  of  the  public  treasury.  I 
am  informed  that  a  solution  containing  two  per  cent,  of  availaljle  chlorine 
could  be  sold  by  the  quantity  as  low  as  40  cents  per  gallon.  This  diluted 
with  four  gallons  of  water  would  give  five  gallons  of  a  prompt  and  reliable 
disinfecting  solution  for  40  cents.  Using  a  pint  of  the  solution  for  each 
liquid  fiecal  discharge,  the  expense  of  disinfection  Avould  be  one  cent  for 
each  dejection. 

The  hypochlorite  of  lime,  to  Avhicli  the  commercial  chloride  of  lime  OAves 
its  A'alue  as  a  disinfectant,  is  equally  effective,  and  still  cheaper.  Accord- 
ing to  Dr.  Duggau  this  contains  usually  from  25  to  40  per  cent,  of 
aA'ailable  chlorine.  One  pound,  therefore,  dissolved  in  from  ten  to  tAventy 
pints  of  water  Avould  give  a  solution  of  calcium  hypochlorite  containing  2 
per  cent,  of  aA^ailable  chlorine.  Diluting  this  to  the  same  extent  as  recom- 
mended in  the  case  of  the  sodium  salt,  avc  Avould  have  from  one  pound  of 
chloride  of  lime  of  the  best  quality  (40  per  cent,  of  available  chlorine) 
twelve  gallons  and  a  half  of  disinfecting  solution,  the  cost  of  which  Avould 
not  exceed  ten  cents.  (By  the  quantity  chloride  of  lime  can  be  purchased 
for  four  to  five  cents  a  pound.)  It  is  hardly  necessary  to  look  for  any- 
thing cheaper  than  this  solution,  and  carefully  conducted  laboratory  ex- 
periments shoAv  that  it  destroys  the  vitality  of  putrefaction  bacteria,  in- 
cluding A'arious  species  of  bacilli  and  their  spores,  Avithin  a  very  brief  time. 


332 


ASIATIC  CHOLERA. 


Eor  the  disinfection  of  clothing  more  dilute  solutions  should  be  used, 
as,  for  example,  one  part  of  Labarraque's  solution  to  100  of  water;  or  one 
ounce  of  bleaching  powder  in  five  gallons  of  water.  For  this  purpose, 
however,  we  prefei-  the  1:5,000  solution  of  mercuric  chloride  heretofore 
recommended. 

Other  disinfectants  might  be  added  to  the  list  if  we  had  need  of  them, 
but  inasmuch  as  they  are  all  inferior  to  those  already  named,  it  is  unnec- 
essary to  devote  much  attention  to  them  in  the  present  chapter.  The 
mineral  acids  are  all  active  germicide  agents,  and  destroy  spores  after 
two  hours  contact  when  present  in  the  proportion  of  8  to  15  per  cent,  (sul- 
phuric 8  per  cent.,  nitric  8  per  cent.,  hydrochloric  15  per  cent.).  In  the  ab- 
sence of  spores  much  weaker  solutions  are  elfective.  Thus  in  the  writer's 
experiments  published  in  the  American  Journal  of  the  Medical  Sciences  in 
April,  1883,  it  was  found  that  sulphuric  acid  in  the  proportion  of  1:  200 
(.05  per  cent.)  destroys  the  vitality  of  B.  iermo  in  active  growth,  and  of 
the  two  species  of  micrococci  experimented  upon. 

Sulphur  Dioxide  in  aqueous  solution — sulphurous  acid — destroys  mi- 
crococci and  bacilli  in  active  growth  in  the  proportion  of  1:  2,000  by 
weight,  the  time  of  contact  being  two  hours.  But  this  agent  is  important 
for  the  destruction  of  spores. ' 

Commercial  sulphurous  acid  would  doubtless  be  effective  for  the  de- 
struction of  cholera  germs  in  a  brief  time  when  diluted  with  fifty  parts 
of  water. 

Sulphur  dioxide  in  gaseous  form,  as  produced  by  the  combustion  of 
sulphur  in  the  presence  of  an  abundant  supply  of  oxygen,  is  commonly 
considered  one  of  the  most  reliable  agents  for  the  disinfection  of  ships, 
hospital  wards,  etc.  There  can  be  no  doubt  of  its  value  for  this  purpose 
when  the  necessary  conditions  are  observed — and  especially  in  the  presence 
of  moisture;  but  recent  experiments  show  that  much  of  the  so-called  dis- 
infection with  this  agent  is  little  better  than  a  farce;  and  it  is  difficult  to 
determine  how  much  of  the  success  which  is  attributed  to  fumigation  with 
sulphurous  fumes  is  due  to  the  germicide  action  of  this  agent,  and  how 
much  to  the  subsequent  ventilation  and  general  cleaning  up  which  sani- 
tary officials  very  properly  insist  upon  as  a  supplementary  precaution.  So 
far  as  the  cholera  germ — "comma-bacillus" — of  Koch  is  concerned,  it 
seems  hardly  necessary  to  resort  to  fumigations  with  sulphurous  acid, 
except  in  the  case  of  ships,  cellars,  etc.,  where  the  presence  of  moisture 
may  serve  to  preserve  the  germs;  for  the  developing  power  of  this  organism 
is  quickly  destroyed  by  desiccation  and  contact  with  atmospheric  oxygen. 
Koch  states  that  when  dried  in  thin  layers  these  organisms  lose  their  vi- 
tality within  three  hours,  and  he  has  never  succeeded  in  starting  cultures 
from  dried  material  which  had  been  kept  even  in  thick  layers  for  a  period 
of  twenty-four  hours. 

The  Metallic  Chlorides  possess  decided  germicide  power,  but,  with 
the  exception  of  mercuric  chloride,  they  are  in  this  respect  much  inferior 
to  the  hypochlorites.  The  solution  of  chloride  of  zinc  of  the  pharmacopoeia 
— liquor  zinci  chloridi — destroys  the  organisms  in  broken-down  beef-tea 
Avhen  present  in  the  proportion  of  ten  per  cent.  (Duggan.)  According  to 
Koch  a  five  per  cent,  solution  of  zinc  chloride  does  not  destroy  the  devel- 
oping power  of  anthrax  spores  after  contact  for  one  month. 

Carbolic  Acid,  which  for  a  time  was  regarded  as  the  germicide  ^x^r 

'  See  the  writer's  paper  in  the  Medical  News,  March  28, 1885. 


INTERNAL    DISINFECTION.  333 

excellence,  cannot  be  relied  upon  for  the  destruction  of  spores,  but  the 
pure  acid  in  one  to  two  per  cent,  sohition  destroys  bacteria  in  active  growth 
within  an  hour  or  two.  It  is  safe  to  say  that  a  five  per  cent,  solution  may 
be  relied  upon  for  the  destruction  of  cholera  germs,  and  of  the  other 
pathogenic  organisms  which  do  not  form  spores. 

Hydrogen  Peroxide  is  another  agent  which  possesses  a  certain  value, 
but  owing  to  the  want  of  stability  and  comparatively  high  price  of  con- 
centrated solutions,  it  is  not  likely  to  replace  the  more  potent  oxidizing 
disinfectants  heretofore  recommended — the  hypochlorites. 

Internal  Disinfection. — Is  it  practicable  to  destroy  cholera  germs  in 
the  alimentary  canal,  and  thus  arrest  the  progress  of  the  disease,  or  pre- 
vent its  development?  And,  if  so,  what  agents  are  best  suited  to  accom- 
plish this  purpose  ?  It  is  impossible  to  answer  these  questions  in  a 
definite  manner  in  the  absence  of  any  carefully  conducted  clinical  experi- 
ments, but  it  may  not  be  unprofitable  to  consider  the  therapeutic  possi- 
bilities from  the  point  of  view  of  the  germ-theory,  and  in  the  light  of 
recent  experiments  which  establish  the  comparative  germicide  value  of 
various  therapeutic  agents.  We  naturally  turn  first  to  the  most  potent 
germicide  in  our  list — mercuric  chloride — an  agent  which,  in  the  proportion 
of  1  part  to  5000  or  less,  would  doubtless  quickly  destroy  all  micro-organ- 
isms in  the  intestine,  of  the  class  to  which  the  cholera  germ  is  supposed 
to  belong.  The  question  is,  first,  whether  it  is  practicable  to  administer 
this  potent  poison  in  doses  which  would,  secure  its  presence  in  the  intestine 
in  this  amount;  and,  second,  whether  by  accomplishing  this  result  we  can 
cure  cholera.  If  we  estimate  the  contents  of  tlae  intestine  at  half  a  litre 
— about  a  pint — the  amount  of  mercuric  choride  necessary  to  disinfect 
this  amount  of  material  may  be  put  at  .1  of  a  grain,  or  about  one  and  a 
half  grains,  a  quantity  considerably  in  excess  of  the  medicinal  dose.  It 
is  evident  that  even  if  this  amount  of  mercuric  chloride  could  be  intro- 
duced into  the  intestine  with  safety,  the  problem  of  getting  it  there  pre- 
sents serious  difficulties,  on  account  of  the  incessant  vomiting  which  occurs 
in  cholera,  and  because  of  the  loss  which  would  result  from  absorption 
through  the  mucous  membraue  of  the  stomach  and  bowels,  and  by  the 
combination  of  the  salt  with  albuminous  material  with  which  it  comes  in 
contact.  The  prospect  of  internal  disinfection  with  this  agent  does  not, 
then,  seem  very  encouraging.  But  mercuric  chloride  in  a  much  smaller 
proportion  than  that  named  has  a  decided  restraining  influence  upon  the 
development  of  bacteria  of  all  kinds,  and  there  is  reason  to  believe  that 
one-tenth  of  this  amount — i.e.,  one  part  to  50,000,  or  .015  of  a  grain — 
would,  if  constantly  present  in  the  intestinal  contents,  notably  and 
perhaps  entirely  restrict  the  growth  of  any  cholera  germs,  or  other  bac- 
terial organisms  present.  This  brings  us  quite  within  the  medicinal  dose 
of  this  agent,  and  to  the  question  of  the  best  method  of  introducing  it  to 
the  place  where  it  is  required,  with  the  least  possible  loss  by  absorption, 
and  the  least  possible  injury  to  the  patient  from  its  toxic  action.  Whether 
this  may  accomplished  by  the  administration  of  calomel,  which,  according 
to  some  authors,  is  converted  by  contact  with  the  chlorides  of  the  stomach 
into  corrosive  sublimate,  is  worthy  of  further  consideration;  but  Ave  are 
inclined  to  agree  with  Dr.  H.  C.  Wood  '  "  that  the  action  of  calomel  upon 
man  is  so  different  from  that  of  corrosive  sublimate  as  to  render  this  theory 
exceedingly  improbable."  Certain  it  is  that  calomel,  in  heroic  doses,  has 
been  thoroughly  tried  in  the  treatment  of  cholera,  and  has  not  been  suc- 

'  Therapeutics,  Materia  Medica  and  Toxicology,  3d  ed.,  p.  396. 


33^  ASIATIC  CHOLERA. 

cessful  in  establishing  itself  as  a  reliable  remedy  for  this  fatal  malady.  In 
a  severe  epidemic  at  a  frontier  station,  which  the  writer  passed  through 
in  18GT,  the  calomel  treatment  was  employed  in  many  cases,  but  without 
any  very  notable  success.  The  impression  remained  upon  my  mind, 
however,  that  when  the  cases  were  seen  early,  this  treatment  had  a  certain 
value  in  favorably  influencing  the  result.  The  ditticulty  in  judging  of  the 
value  of  any  method  of  treatment  is  greatly  enhanced  by  the  fact  that 
many  cases  during  the  prevalence  of  an  epidemic  are  not  seen  until  fatal 
poisoning  has  alread}'  occurred.  A  patient  in  the  algid  stage  of  the 
disease  is  evidently  suffering  from  the  effects  of  a  poison  which  has  already 
been  absorbed,  and  which  acts  powerfully  upon  the  vaso-motor  nervous 
system. 

The  pressing  indication  when  a  patient  is  seen  in  the  stage  of  collapse, 
is  evidently  to  neutralize  the  manifest  eii'ects  of  the  toxic  agent,  rather 
than  to  attempt  to  kill  the  cholera  germs  in  the  intestine,  which  we  sup- 
pose to  have  produced  it.  At  the  same  time  it  is  very  probable  that  a  fatal 
result  depends,  to  some  extent  at  least,  upon  the  continued  production 
and  absorption  of  the  poison,  and  we  must  not  neglect  to  kill  the  germs, 
or  restrict  their  development,  if  any  practicable  means  of  accomplishing 
this  object  presents  itself.  If  the  patient  dies  notwithstanding  the 
administration  of  germicide  remedies  during  this  stage,  it  does  not  follow 
that  treatment  with  agents  of  this  class  is  futile.  It  may  be,  simply,  that 
the  treatment  was  commenced  too  late.  To  kill  a  murderer  after  his  vic- 
tim has  been  fatally  wounded,  does  not  save  the  life  of  the  murdered  man. 
Experience  proves  that  the  time  for  successful  treatment  is  during  the 
"  premonitory  stage,''  when  the  chief  symptoms  are  a  certain  looseness  of 
the  bowels  and  a  feeling  of  lassitude.  The  deadly  germ  is  no  doubt  already 
present  at  this  time;  the  toxic  product,  as  a  result  of  its  vital  activity  evolved, 
is  being  absorbed,  and  perhaps  has  a  cumulative  effect, until  finally  the  nerv- 
ous centers  are  overwhelmed  and  we  have  the  frightful  symptoms  of  the 
stage  of  collapse  rapidly  developed. 

That  cholera  is  very  amenable  to  treatment  during  the  first  stage  of 
"premonitory  diarrhoea  "is  generally  conceded  by  those  who  have  seen 
the  most  of  this  disease,  and  any  abortive  treatment  based  upon  the  ger- 
micidal action  o'f  the  remedies  employed  should  be  applied  during  this 
stage.  The  object  in  view  should-  be  to  cause  the  remedy  to  come  in  con- 
tact with  the  material  to  be  disinfected,  with  the  least  possible  loss  from 
vomiting  or  by  absorption.  Calomel  has  the  advantage  of  easy  adminis- 
tration, and  of  being  retained  by  the  stomach  when  other  remedies  might 
be  rejected.  But  the  administration  of  calomel  with  a  view  to  the  forma- 
tion and  germidical  action  of  corrosive  sublimate  is  a  very  unscientific  pro- 
ceeding. In  the  first  place  it  is  uncertain  whether  the  conversion  of  a 
portion  of  the  calomel  into  bichloride  occurs  at  all;  and  in  the  next  place, 
it  is  evident  that  the  amount  formed  would  be  so  much  a  matter  of  acci- 
dent that  the  attempt  to  kill  germs  in  this  way  would  be  like  shooting  at 
a  flock  of  partridges  with  one's  eyes  shut. 

If  mercuric  cliloride  is  to  be  fairly  tested  it  must  be  administered  in 
definite  amount,  and  at  definite  intervals;  and  it  would  seem  as  if  the  in- 
dications might  be  best  fulfilled  by  the  administration  of  small  amounts  at 
frequent  intervals.  "We  Avould  suggest,  for  example,  upon  theoretical 
grounds,  that  granules  containing  y-J-o-  of  a  grain  of  mercuric  chloride, 
mixed  with  milk  sugar  (?),  and  coated  Avith  some  substance  which  does 
not  dissolve  too  quickh',  might  be  administered,  two  at  a  time,  every  five 


INTEENAL   DISINFECTION.  335 

minutes,  for  an  hour  (=  y"|-,-i,j  of  a  grain),  then  every  ten  minutes  for  two 
hours  (=  in  all  yVV  of  a  grain).  After  this  one  granule  every  ten  minutes 
might  perhaps  suffice  to  keep  the  contents  of  the  bowels  "in  an  aseptic 
condition.  It  may  he  that  larger  doses  would  be  tolerated,  or  that  in 
practice  it  will  be  found  better  to  give  the  medicine  in  dilute  solution — 
1 :  5000.  The  writer  would  not  be  understood  as  recommending  a  treat- 
ment which  he  has  not  tried,  but  simply  as  suggesting  a  clinical  experiment. 

The  dose  of  liquor  soda?  chlorinate  is  given  by  the  U.  8.  Dispensatory 
as  30  drops  to  a  fluid  drachm,  largely  diluted  with  water;  that  of  chloride 
of  lime  is  siiid  to  be  from  three  to  six  grains,  dissolved  in  sweetened  water. 
These  doses  frequently  repeated  would  doubtless  exercise  a  restraining  in- 
fluence upon  the  development  of  germs  in  the  alimentary  canal,  but  are 
inadequate  for  the  complete  disinfection  of  its  contents.  Both  of  these 
agents  have  been  recommended  for  the  treatment  of  "putrid"  fevers  and 
dysentery,  attended  with  fetid  discharges.  Labarraque's  solution  is  the 
most  eligible  preparation  for  internal  administration,  and  the  experiment 
of  giving  it  in  dilute  solution  at  frequent  intervals  might  be  worth  trying. 

Another  agent  mentioned  in  our  list  of  disinfectants  which  has  doubt- 
less a  certain  medicinal  value,  depending  upon  its  antiseptic  and  germicide 
l^ower,  is  sulphurous  acid.  It  may  be  given  in  doses  of  30  drops  to  a 
drachm,  largely  diluted  with  water,  and  to  secure  the  effect  desired  should 
be  given  at  frequent  intervals.  If  it  could  be  introduced  directly  into  the 
intestine  in  capsules,  this  would  appear  to  be  a  preferable  way  of  admin- 
istering it. 

The  "  comma-baciUus ''  of  Koch  grows  best  in  media  having  a  slightly 
alkaline  reaction,  and  its  development  is  retarded  or  prevented  entirely  by 
the  presence  of  free  acids  in  small  amounts.  A  knowledge  of  this  fact 
furnishes  an  indication  for  a  method  of  treatment  which  has  already  been 
tested  empirically  and  in  favor  of  which  there  is  considerable  evidence, 
viz.,  the  administration  of  the  mineral  acids  in  dilute  solution,  and  es- 
pecially of  sulphuric  acid.  The  j^rophylactic  value  of  "  sulphuric  acid  lem- 
onade"' seems  to  be  established  by  the  facts  reported  by  Dr.  E.  G.  Curtin, 
in  the  Philadelphia  Medical  Times  (vol.  iii.,  p.  049).  A  severe  epidemic 
of  cholera  which  had  broken  out  in  the  insane  department  of  the  Phila- 
delphia almshouse  was  apparently  arrested  within  twelve  hours  by  caus- 
ing all  of  the  inmates  to  drink  freely  a  ' '  lemonade  "  made  with  diluted 
sulphuric  acid.  The  only  new  case  after  the  commencement  of  this  pro- 
phylactic treatment  was  a  man  Avho  refused  to  drink  the  solution.  Two 
new  cases  occurred  on  the  second  day  after  the  acid  drink  had  been  dis- 
continued, but  upon  resuming  this  the  progress  of  the  disease  was  again 
arrested. 


SECTIO]^    II. 


THE  PREVExNTION  OF  THE  SPREAD  OF  CHOLEEA. 


BY 

JOHN  B.  HAMILTON,  M.D., 

SUPERVISING   SURGEON-GENERAL  OF   THE  MARINE  HOSPITAL   SERVICE  OF  THE 

UNITED   STATES. 


9^ 


THE  RESPONSIBILITY  OF  NATIONS.  339 


CHAPTEE  XXXIX. 

EESPONSIBILITY  OF  NATIONS  AND  INTERNATIONAL  NOTIFICATION. 

Responsibility  of  Nations. — If  we  examine  the  history  of  past 
epidemics  we  find  that  almost  Avithout  exception  the  appearance  of 
cholera  in  any  given  locality  may  he  traced  to  importation  from  its 
endemic  habitat.,  and  that  in  the  exceptional  instances  where  it  has 
seemed  impracticable  to  so  trace  it,  the  initial  case  has  been  in  donbt, 
and  the  failure  was  due  simply  to  lack  of  proper  surveillance  and 
inquiry.  Modern  views  as  to  the  prevention  of  the  spread  of  epidemic 
disease  in  general,  and  cholera  in  particular,  are  governed  by  the  belief  that 
the  infectious  matter  of  such  diseases  is  a  material  particulate  poison,  with 
the  weight  of  evidence  in  favor  of  the  opinion  that  the  materies  morbi, 
is  a  living  thing  or  organism,  capable  of  being  transported  in  certain  arti- 
cles which  for  convenience  sake  we  term  f omit e-s.  The  exclusion  of  these 
organisms,  upon  the  one  hand,  or  their  destruction  upon  the  other,  is  the 
respective  basis  of  the  principle  of  home  quarantine  and  disinfection. 

I  shall  proceed  to  discuss  the  methods  of  performing  this  service  in 
detail,  but  before  doing  so  let  me  refer  to  a  broader  topic — that  o*f  arrest- 
ing cholera  at  its  endemic  center,  which  is  the  essence  of  prevention.  A 
national  government  deriving  "  its  just  powers  from  the  consent  of  the 
governed,''  during  its  existence  as  a  government,  must  assume  certain 
responsibilities,  among  which  are  those  affecting  the  physical  and  pecu- 
niary welfare  of  the  people.  A  government  must  under  the  natural  limi- 
tations of  human  rights,  take  the  proper  and  necessary  measures  to  protect 
its  subjects  against  pestilence  or  famine,  by  such  wise  and  prudent  acts 
as  the  necessities  of  the  time  may  seem  to  warrant.  A  failure  so  to  do 
would  subject  such  a  government  in  the  eyes  of  all  civilized  peoples  to 
just  condemnation,  and  as  the  safety  of  nations  makes  them  mutually  in- 
terdependent, whether  they  will  it  or  not,  so  the  safety  of  a  particular 
nation  is  dependent  upon  the  physical  integrity  of  its  several  municipali- 
ties, as  well  as  upon  the  physical  integrity  of  its  neighbors.  This  re- 
sponsibility must  be  conceded  by  the  political  economist,  and  the  govern- 
ing motive  then  becomes  a  question  of  the  relative  weight  of  responsibilities 
which  apparently  conflict.  Thus  if  we  are  debarred  from  commercial 
intercourse  by  reason  of  our  fear  of  the  importation  of  a  contagious  dis- 
ease, that  deprivation  may  result  in  famine  of  greater  or  less  degree,  and 
this  as  here  stated  in  extreme  terms,  furnishes  the  key  to  the  reason  of 
the  great  and  apparent  irreconcilable  differences  of  opinion  as  to  the 
maintenance  of  C[uarantine.  Modern  nations  have  tacitly  recognized 
these  responsibilities  and  endeavored  to  meet  them  by  ''international 
conferences,"  rarely  however  with  any  view  to  mutual  concession.  At 
each  "conference"  thus  far  held,  the  commercial  phase  of  the  question 
has,  although  purposely  kept  in  the  background,  seemed  to  be  paramount; 


340  ASIATIC  CHOLERA. 

and  although  there  has  been  substantial  agreement,  first  as  to  the  respon- 
sibility of  any  nation  having  epidemic  disease  within  its  borders,  that  such 
disease  should  not  be  allowed  through  negligence  to  affect  its  neighbor; 
and  second,  as  to  the  desirability  of  a  synchronous  united  effort  looking 
toward  final  eradication ;  yet  the  moment  the  details  by  Avhich  these  desirable 
ends  were  to  be  attained  Avere  discussed,  harmony  was  at  an  end,  and  so 
up  to  this  time  it  has  happened  that  each  nation  for  itself  assumes  its 
own  responsibilities  toward  its  citizens,  and  allows  its  neighbor  to  adopt  in 
turn  such  independent  measures  as  in  its  judgment  the  occasion  warrants. 
International  law  is  silent  upon  the  question,  and  although  the  usage  of 
nations  respecting  invasion  of  neighboring  territory  by  armed  forces,  or 
bandits;  the  enforced  sale  of  provisions  to  starving  troops — in  a  word,  the 
general  acts  of  necessity — are  provided  for,  no  provision  or  understanding 
has  yet  been  arrived  at  concerning  the  responsibility  of  nations  in  the  par- 
ticular of  the  transmission  of  epidemic  diseases.  If,  for  instance,  Germany 
or  France  should  say  to  Great  Britain,  "  You  are  in  command  of  India,  and 
in  retaining  that  command  you  have  failed  to  stamp  out  the  cholera,  which 
is  at  intervals  destroying  large  numbers  of  our  people,  therefore  we  will 
proceed  to  India,  and  ourselves  execute  the  necessary  sanitary  measures, '' 
that  would  amount  to  a  declaration  of  war.  The  Indian  and  home  gov- 
ernment would  rise  up  to  resist  invasion  and  the  presence  or  absence  of 
cholera  would  be  lost  sight  of  in  the  ensuing  conflict.  It  is  therefore  clear 
that  international  public  sentiment  must  be  created  to  compel  those 
nations  owning  cholera  and  yellow  fever  centers,  to  no  longer  afflict  the 
globe  by  their  apathy  and  indifference  to  the  general  welfare.  Russia,  as 
will  be  seen  further  on,  set  an  example  in  relation  to  plague  that  is  worthy 
of  commendation  and  might  profitably  be  followed  by  other  nations. 

It  may  be  claimed  that  England  cannot  enforce  in  India  those  salutary 
and  stringent  regulations  which  she  does  at  home  in  so  admirable  a  man- 
ner, but  to  that  it  must  be  replied  that  the  true  doctrine  of  government 
implies  the  acceptance  of  such  responsibility  with  the  reins  of  administra- 
tion. 

Spain,  in  the  destruction  of  the  yellow  fever  centers  of  her  AYest  Indian 
possessions,  has  an  easier  task,  owing  to  the  smaller  area  of  the  infected 
territory,  and  the  lesser  engineering  difficulties.  It  is  stated,  for  instance, 
that  the  tideless  stagnant  water  about  the  infected  wharves  and  docks  in 
the  harbor  of  Havana  might  be  regularly  swept  by  tidal  currents  by  cut- 
ting a  short  canal.  And  who  can  doubt  that  if  the  action  of  Russia  in 
respect  of  the  plague  were  imitated  by  Great  Britain,  Burmah  and  China 
as  regards  cholera;  Spain,  Brazil,  Central  America  and  Mexico,  in  re- 
spect of  yellow  fever,  that  those  two  diseases  would  speedily  disappear 
from  the  earth.  This  is  not  a  merely  visionary  idea,  for  it  commends 
itself  to  human  reason,  and  Avhen  once  the  doctrine  of  res2)onsibility  is  con- 
ceded, and  etiological  facts  are  agreed  upon,  the  necessary  action  can  be 
enforced  under  penalty  of  commercial  ostracism. 

International  Notification. — Within  the  last  few  years,  most  nations 
have  adopted  a  system  of  "  sanitary  notification  "  for  their  own  protection. 
As  at  present  practiced,  this  notification  emanates  from  the  various  consular 
officers.  The  consul  of  a  country  at  a  foreign  city  is  required  to  notify 
the  home  government  at  stated  times  of  the  sanitary  condition  of  the  port 
or  place,  or  "consular  district"  where  he  is  stationed.  Some  countries, 
and  among  them  the  United  States,  require  consular  officers  to  inform  the 
home  government  by  telegraph  of  the  outbreak  of  an  epidemic,  and  when 


INTERNATIONAL   NOTIFICATION. 


341 


necessary  or  expedient,  the  progress  of  tlie  epidemic  is  reported  by  telegraph 
daily.  tJnder  authority  of  Section  1T52  of  the  United  States  Statutes, 
consular  regulations  have  been  issued  which  require  the  consul  to  notify 
the  port  of  destination  as  well  as  the  department,  of  the  departure  of  a 
vessel  from  an  infected  port,  or  one  carrying  infected  passengers  or  goods. 
For  many  years,  in  countries  where  certain  contagious  diseases  are  endemic, 
the  British  consulates  have  employed  a  physician,  and  the  medical  geog- 
raphy of  the  country  thus  obtained  has  been  of  great  value  not  only  to  the 
home  government  but  to  other  countries  as  well.  The  admirable  papers 
in  the  "  Chinese  Customs  Gazette  "  furnish  an  example  of  what  may  be  done 
b}^  intelligent  medical  men  in  connection  with  the  consular  service.  The 
consuls  of  the  United  States  are  required  to  make  a  weekly  report  of  the 
sanitary  condition  of  their  consular  district  upon  the  following  form: 

18 

To  the  Honorable 

The  Secretary  of  State, 

Washington,  D.  C,  Zliited  States  of  America. 
In  compliance  with  tlie  act  of  April  39, 1878, 1  have  the  honor  to  make  the  fol- 
lowing report  of  contagious  diseases,  and  deaths  occun-ing  therefrom,  at  this 

place,  during  the  week  ended ,  18.  .,  for  the  information 

of  the  Surgeon  General  of  the  Marine  Hospital  Service: 


Cases. 

Deaths 

1 

Cases  treated  in       Deaths  ix  Hospitals 
HospiT.\LS  iMilitaiy,       Olilitary.  Civil  and 
Civil  and  Private).                   Private). 

Cholera 

Yellow  Fever 

Sniall-pox 

Tj-phus  Fever  (or  Ship  Fever) 
Enteric  (or  Typhoid)  Fever  .  . 
Scarlet  Fever 

Diphtheria 

Plague 

Totals 

Total  deaths //-ofH  ait  causes  during  the  week  reported 

Population  according  to  census  of ,  18. . . , 

Present  officially  estmiated  population, 

Weeklv  mean  of  the)inometer, Weekly  mean  of  barometer, . 

Prevailing  diseases,  (and  other  pertinent  information,) 


Very  respectfully. 

The  law  under  which  the  foregoing  report  is  required  is  the  following 
section  of  the  unrepealed  portion  of  the  Act  of  April  29,  187S,  known  as 
the  Xational  Quarantine  Act: 

"That  whenever  any  infectious  or  contagious  disease  shall  appear  in  any 
foreign  port  or  country,  and  whenever  any  vessel  shall  leave  any  infected 
foreign  port,  or  having  on  lioard  goods  or  passengers  coming  from  any  place 
or  district  infected  with  cholera  or  yellow  fever,  shall  leave  any  foreign  port, 
bound  for  any  port  in  the  United  States,  the  consular  officer,  or  other  rep- 
resentative of  the  United  States  at  or  nearest  such  foreign  port,  shall  im- 
mediately give  information  thereof,  and  shall  report  the  name,  date  of 
departure,  and  the  port  of  destination  in  the  United  States;  and  the 
consular  officers  of  the  United  States  shall  make  Aveekly  reports  of  the 
sanitary  condition  of  the  ports  at  which  they  are  respectively  stationed." 


342  ASIATIC  CHOLERA. 

The  enactment  of  this  law  is  dne  perhaps  in  greatei*  degree  to  the 
efforts  of  the  late  Surgeon-General  John  M.  "NVoodworth  than  to  those 
of  any  other  one  man  outside  of  Congress.  Four  years  before,  in  the 
report  on  the  Cholera  Epidemic  of  1873,  Doctor  Woodworth  wrote: 

What  is  needed  is,  that  the  National  Government,  tliroiigh  its  consular 
officers,  at  least  at  each  port  of  departure  sliall  acquire  the  necessary  information, 
and  then  promptly  and  intelligently  furnish  it  to  the  ports  and  localities  exposed. 
This  is  entirely  aside  from  a  national  quarantine  board,  a  national  bureau  of 
health,  or  other  specific  organization,  concerning  the  present  wisdom  and  expedi- 
ency of  which  opinion  at  least  is  not  unanimous.  It  is  a  simple  utilization  of 
already  existing  machinery  on  tlic  part  of  tlie  general  government,  for  the  acqui- 
sition "of  knowledge  indispensable  to  the  general  welfare.  Such  knowledge  cannot 
through  its  own  agents  be  acciuired  by  a  State  or  by  a  municipality,  yet  upon  sucli 
knowledge  and  action  does  the  future  immunity  from  Cliolera  of  the  country  at 
large  depend. 

A  circular  letter  from  the  President,  through  the  Department  of  State,  in- 
structing consular  officers  to  place  themselves  in  communication  with  the  health 
authorities  of  their  respective  localities:  to  advise  promptly,  by  cable  if  necessary, 
of  the  outbreak  of  cholera  (or  other  epidemic  disease)  at  their  ports  or  any  section 
in  communication  therewith,  to  inspect  all  vessels  clearing  for  United  States  ports 
Avith  reference  to  the  original  and  intermediate  as  well  as  to  the  final  points  of 
departure  of  emigrants  "thereon;  and  to  report  always  by  cable  the  sailing  and 
destination  of  any  such  vessel,  carrying  infected  or  suspected  passengers  or  goods 
— this  should  lie  the  first  step. 

And  tlie  next  would  be  equally  simple:  A  medical  officer,  selected  for  his  good 
judgment  and  attainments  in  sanitary  science,  should  collect  and  digest  the  in- 
formation thus  obtained,  and  transmit  to  the  threatened  ports,  as  well  as  through 
the  public  press,  the  note  of  warning.  Thus  advised,  the  threatened  community 
would  have  ample  time  for  preparation,  and  the  publicity  given  to  the  warning- 
would  be  the  most  efficient  means  of  insuring  proper  precautionary  measures. 

At  the  International  Sanitary  Conference  of  Washington,  much  stress 
appears  to  have  been  laid  upon  the  bill  of  health  issued  to  vessels,  and 
after  a  long  discussion  of  that  and  kindred  topics,  the  following  form  of 
a  bill  of  health  for  international  use  was  adopted  without  dissent: 

LXTERXATIONAL  BiLL  OF   HEALTH. 

I, (the  person  charged  to  deliver  the  bill),  at  the  port  of 

do  hereby  state  that  the  vessel  hereinafter  named  clears  from  this 

port  under  the  followmg  circumstances: 

Name  of  vessel Natvire  (vessel  of  war,  shiji,  schooner,  etc.). 

Tonnage ;  Apartments  for  passengers;  No ;  Guns ; 

Destination ;  Where  last  from ; 

Name  of  medical  officer  (if  any) ;  Name  of  captain ; 

Total  number  of  passengers:  1st  cabin, ;  2d  cabin, ;  steerage, ; 

Total  number  of  crew,  .  .  .  .  ;  Cargo,  .... 

Vessel. — Sanitary  condition  of  vessel  (before  and  after  reception  of  cargo,  with 
note  of  any  decayed  wood). 

1.  Note  disinfection  of  vessel 

2.  Sanitary  condition  of  cargo 

3.  Sanitary  condition  of  crew 

4.  Sanitary  condition  of  passengers 

5.  Sanitary  condition  of  clothing,  food,  water,  air,  space  and  ventilation 

Port. — 1.  "Sanitary  condition  of  "port  and  adjacent  country  

a.  Prevailing  diseases  (if  any) 

b.  Number  of  cases  of  and  deaths  from  yellow  fever,  Asiatic  cholera,  plague, 
small-pox  or  tvphus  fever  during  the  week  preceding. 

Xu  mbev  of  cases  of  Numbe7^  of  deaths  from 

Yellow  fever —        Yellow  fever — 

Asiatic  cholera —        Asiatic  cholera — 

Plague —        Plague — 

Small-pox —        Small-pox — 

Typhus  fever —        Typhus  fever — 

c.  Population  according  to  the  last  census 

d.  Total  deatlis  from  all  causes  during  the  preceding  month 


INTERNATIONAL  NOTIFICATION.  343 

2.  Any  circainistances  affecting  the  public  health  existing  in  the  port  of  depart- 
ure to  be  here  stated 

I  certify  that  the  foregoing-  statements  are  made  by ,  who  has 

personally  inspected  said  vessel;  that  I  am  satisfied  that  the  said  statements  are 
correct,  and  I  do  further  certify  that  the  said  vessel  leaves  this  port  bound  for 
in 

In  witness  whereof  I  have  hereunto  set  my  hand  and  the  seal  of  office,  at  the 

port  of ,  this day  of ,  188   ,  . . .  .  o'clock. 

[SEAL.]  [Signature.] 

But  it  is  foiTnd  in  practice  tliat  tlie  bills  of  health  are  in  some  cases 
untrustworthy  and  are  not  to  be  depended  upon  at  our  ports,  and  the 
quarantine  officer  must  rather  act  upon  information  otherwise  received 
by  him  concerning  the  sanitary  state  of  the  port  of  departure.  Thus 
while  this  is  being  written  yellow  fever  is  prevalent  in  epidemic  form  on  the 
isthmus  of  Panama,  and  yet  no  bill  of  health  from  Panama  or  Aspinwall 
gives  a  statement  of  the  existence  of  such  an  epidemic.  This  does  not  imply 
that  the  consul  is  neglectful,  but  he  is  obliged  to  accept  the  statement  of 
the  duly  constituted  health  authorities  of  the  country,  and  a  refusal  so  to 
do  would  result  in  the  withdrawal  of  his  exequatur.  In  such  cases  he 
can  only  notify  his  government.  At  the  Sanitary  Conference  of  Wash- 
ington, no  representative  was  willing  to  agree  that  the  "  certifying  author- 
ity ''  of  the  port  of  departure  should  be  other  than  the  local  authority, 
and  as  in  the  case  of  Panama,  and  perhaps  instances  nearer  home,  the  fear 
of  being  placed  at  a  commercial  disadvantage  has  operated  as  a  powerful 
motive  for  concealment  of  contagious  disease. 

The  Conference  of  "Washington  went  much  further  in  the  matter  of 
perfecting  a  plan  for  International  notification  than  any  of  the  preceding 
conferences.  Kesolutions  III.  and  IV.  adopted  by  the  Conference  are  as 
follow: 

m.  In  the  interest  of  the  public  health,  the  sanitary  authorities  of  the  countries- 
represented  in  this  conference  are  authorized  to  communicate  directly  with  each 
other  in  order  to  keep  themselves  informed  of  all  important  facts  which  may 
come  to  tiieir  knowledge;  but  nothing-  herein  contained  shall  relieve  them  fronx 
the  duty  of  furnishing  at  the  same  time  to  consuls  in  their  respective  jurisdic- 
tions the  information  they  are  required  to  g-ive  them. 

rV.  A  centralized  international  system  of  sanitaiy  notification  being  deemed 
indispensable  to  the  successful  carrying-  out  of  measures  for  preventing  the  intro- 
duction of  disease,  it  is  advisable  to  create  international  organizations  to  be 
charged  with  the  duty  of  collecting  information  in  regard  to  the  outbreak,  spread 
and  disappearance  of  cholera,  pest,  yellow  fevers,  etc.,  and  of  conveying  such  in- 
formation to  the  parties  interested. 

The  representatives  of  the  United  States,  at  the  conference,  voted 
against  the  latter  of  these  resolutions,  but  it  Avas  adopted  by  a  vote  of  13 
to  3. 

The  ])lan  by  which  it  was  proposed  to  carry  out  resolution  IV.  of  the 
conference  is  as  follows: 

Annex  I, 

The  draft  of  a  convention  mentioned  in  Resolution  FV.  is  as  follows: 

Article  I.  There  shall  be  establisheil  in  Vienna  and  Havana  a  permanent  Inter- 
national Sanitary  Agency  of  Notification.  The  respective  governments  shall 
agi'ee  among  tliemselves  as  to  the  formation  of  those  agencies. 

Art.  n.  it  will  be  the  duty  of  the  agency  at  Vienna  to  gather  sanitary  infor- 
mation from  Europe,  Asia  and  Africa.  The  agency  at  Havana  will  extend  its 
sphere  of  action  to  the  American  Continent  and  the  islands  belonging  geograph- 
ically thereto.  This  system  to  be  subject  to  such  modifications  as  may  be  ren- 
dered necessary  by  the  state  of  telegraphic  communication. 

Art.  m.  The  contractmg  governments  shall  have  the  i-ight  to  establish,  if 
necessar\',  a  third  agency  in  Asia. 


344 


ASIATIC  CHOLERA. 


Art.  rv^.  The  governments  agreeing  to  this  system  of  notification  will  send 
their  sanitary  reports  to  that  agency  in  whose  jurisdiction  it  is.  Every  agency 
sliall  send  its  notifications  to  those  governments  sending  sanitarj'  bulletins.  The 
different  agencies  will  exchange  the  information  they  receive  among  themselves 
in  order  that  it  may  be  made  known  to  the  respective  countries  belonging  to  the 
jurisdiction  of  each. 

Art.  V.  There  shall  be  no  exceptions  to  this  sj'stem,  save  in  cases  of  extreme 
emergency.  In  such  cases,  however,  a  government  may  enter  into  communica- 
tion with  an  agency  to  whose  jurisdiction  it  does  not  belong. 

Art.  VI.  In  cases  of  doubt  as  to  correctness  of  the  bulletins  received,  the 
agency  is  authorized  to  entei-  into  communication  with  the  respective  govern- 
ments, who  will  be  obliged  to  furnish  as  soon  as  possible  the  information  asked. 

Art.  VII.  In  those  countries  where  international  sanitary  boards  exist  the 
agencies  shall  establish  communication  with  them. 

Art.  VTTT.  In  those  countries  which  have  not  a  perfect  sanitary  organization, 
or  which  have  not  adopted  the  conclusions  of  this  conference,  the  consuls  of  the 
contracting  powers  shall  meet  in  an  International  Sanitary  Council  in  order  to 
give  to  the  said  agencies  the  information  which  cannot  be  obtained  from  the  local 
autliorities. 

Art.  IX.  The  Governments  of  Spain  and  Austria-Hungaiy  shall  fix  the  annual 
budget  of  expenses,  which  they  will  submit  to  the  participating  governments. 

Art.  X.  The  division  of  expenses  between  the  different  governments  shall  be 
as  follows:  Half  of  the  expense  will  be  divided  in  pro]X)rtion  to  the  number  of 
population,  and  the  other  half  in  proportion  .to  the  amount  of  tonnage  of  the 
merchant  marine  combined  with  the  commercial  maritime  value  of  everj'  country. 

Art.  XI.  The  Governments  of  Spain  and  Austria-Hungary  shall  submit  at  the 
end  of  every  fiscal  year  the  final  accounts  to  every  one  of  the  interested  govern- 
ments. 

Art.  XII.  The  present  convention  is  concluded  for  the  space  of  ten  yeai*s.  Any 
government,  however,  is  at  liberty  to  renounce  the  Convention  after  three  years. 
The  right  is  reserved  to  make  such  changes  as  any  one  of  the  governments 
taking  part  shall  designate. 

But  none  of  the  governments  sending  representatives  to  the  Conference 
have  agreed  to  the  rules  and  regulations  there  suggested. 

After  all  there  is,  perhaps,  no  better  plan  than  that  adopted  by  Great 
Britain  and  the  United  States,  namely,  when  information  is  wanted  to  call 
upon  its  own  officers  to  furnish  it,  and  tliento  publish  the  result.  Under 
existing  appropriation  acts,  a  medical  officer  can  be  attached  to  any  U.  S. 
Consulate  whenever  believed  to  be  necessary  or  essential. 


THE   THEORY   OF   QU^\JIANTINE.  345 


CHAPTER   XL. 

MEDICAL  INSPECTION,  INCLUDING  THE  THEORY  AND  PRACTICE  OF 

QUARANTINE. 

I.  The  Theory  of  Quarantine. — Xo  one  wlio  has  studied  without 
preconceived  ideas  or  prejudice  can  fail  to  conckide  that  if  the  germs  of 
cholera  were  excluded  from  a  country,  that  country  would  certainly  escape 
an  epidemic.  It  is  for  the  purpose  of  assisting  in  the  work  of  exclusion  of 
disease  germs  that  quarantines  are  now  maintained,  and  medical  inspections 
instituted.  It  is  true  that  the  history  of  quarantine  shows  that  its  beginning 
Avas  purely  empirical,  for  the  city  in  the  sea  that  had  the  first  lazaretto  was 
forced  thereto  by  necessity.  Venice  Avas  the  great  commercial  entrepot  of 
the  Mediterranean;  her  sails  whitened  the  horizon  of  every  known  harbor, 
and  lier  returned  vessels  crowded  her  own  docks.  Her  great  commerce 
made  a  flourishing  carrying  trade,  and  stimulated  travel,  but  at  the 
same  time  brought  fomites  to  her  households.  There  were  repeated  epi- 
demics the  origin  of  which  was  traced  either  to  the  returned  merchants, 
their  sailors  or  their  ships.  Hence  those  wise  Adriatic  shop-keepers  who 
valued  life  even  above  shekels,  concluded  to  place  restrictions  upon  the 
carrying  trade,  so  that  by  detention  they  might  conclude  Avhether  or  not 
a  particular  vessel  was  infected,  before  allowing  her  entry  into  the  port. 
They  fixed  upon  the  i:)eriod  of  forty  days  as  the  time  necessary  for  such 
detention:  hence  the  term  quarantine.  The  time,  as  we  now  believe,  was 
unnecessarily  long;  the  consequent  detention  cruel  and  liazardous,  but 
for  many  years  it  was  rigidly  maintained,  and  although  the  time  of  deten- 
tion has  been  everywhere  reduced,  it  is  still  tedious  and  productive  of  much 
hardship  at  many  ports.  The  dangers  of  this  excessive  caution,  the  fear 
of  commercial  losses,  and  their  reflex  influence  upon  medical  teachings 
have  operated  as  powerful  agents  against  the  entire  system.  Thus  there 
have  appeared  violent  invectives  against  the  practice  of  quarantine  from 
many  who  should  have  been  counted  among  its  suporters. 

Professor  Stille,'  who  has  examined  this  question  with  that  candor  and 
regard  for  worthy  opponents  that  has  always  been  characteristic  of  him 
says:  ''  There  is  urged  against  the  enforcement  of  a  rigid  quarantine  by 
land  or  sea  the  singular  argument  that  it  has  not  always  excluded  the  dis- 
ease. A  more  logical  inference  Avould  seem  to  be  that  since  it  succeeded, 
not  completely,  but  yet  partially,  its  inefficiency  should  be  charged  to  its 
imperfect  execution ;  or  even  granting  that  the  absolute  exclusion  of  cholera 
is  impracticable  in  every  instance,  including  cases  of  choleraic  diarrhoea, 
contaminated  clothing,  and  merchandise,  does  it  follow  that  the  transit  of 

'  Loc  citat. ,  p.  755-56. 


146 


ASLITIC  CHOLERA. 


men  and  things  should  be  unimpeded  ?  As  well  might  it  be  maintained  that 
because  one  or  more  houses  cannot  escape  destruction  by  fire,  therefore 
no  effort  should  be  made  to  save  the  remainder  of  a  threatened  city;  as 
well  might  it  be  argued  that  because  some  men  must  be  killed  in  battle 
no  precautions  should  therefore  be  used  to  preserve  the  rest  of  the  army; 
as  Avell  abstain  from  all  local  sanitation  intended  to  mitigate  the  ravages 
of  the  disease  because  some  victims  it  will  surely  have.  This  is  taking 
counsel  from  despair — is  a  stupid  fatalism  which  one  might  imagine  to 
have  been  imported  with  the  disease  from  the  East.     .     .     . 

"  Probably  no  sanitary  cordon  nor  any  quarantine  will  invariably  and 
completely  exclude  cholera,  since  it  is  transmissible  by  living  men,  and  by 
water  and  by  fomites  of  various  descriptions,  and  worst  of  all  by  men 
who  neither  exhiljit  its  characteristic  symptoms  nor  are  conscious  of  the 
poison  which  they  conceal  and  disseminate.  But,  as  has  already  been  urged, 
it  is  no  argument  against  preventive  measures  that  they  are  not  absolutely 
perfect  in  their  efficiency.  If  they  sometimes  succeed  in  arresting  the 
progress  of  cholera,  and  if  they  always  when  honestly  executed  lessen  the 
number  of  channels  through  which  the  infection  can  be  conveyed,  and 
thereby  reduce  to  a  minimum  its  fatal  effects,  they  ought  to  be  maintained 
and  perfected  and  not  decried  or  abolished.  It  is  difficult  to  character- 
ize that  state  of  mind  which  concludes  against  the  use  of  a  salutary 
measure  because  its  efficiency  is  not  absolute,  the  more  so  when  it  is  ad- 
mitted that  its  inefficiency  is  not  intrinsic  but  due  to  negligent  and  fraud- 
ulent administration. " 

It  would  fill  more  pages  in  this  volume  than  are  at  the  writers  disposal 
to  give  brief  details  or  perhaps  even  to  simply  enumerate  all  the  instances 
where  the  observance  of  strict  quarantine  has  apparently  resulted  in  the 
escape  from  an  epidemic  elsewhere  prevailing.  The  writer  having  due 
regard  for  the  argument  that  these  instances  are  but  examples  of  the  j^ost 
hoc  ergo  propter  hoc  fallacy,  must  conclude  that  the  germ  theory  itself  is 
the  best  possible  argument  in  favor  of  the  effectivness  of  rigid  quarantine. 
Even  if  we  adopt  the  theory  that  the  poison  is  inorganic,  the  evidence  of 
centuries  of  observation  proves  it  to  be  transportable;  being  transportable 
it  must  be  possible  to  prevent  its  transportation  by  the  exclusion  of  the 
vehicles  of  transportation— /b^w/Y^'^.  From  this  conclusion  there  seems  no 
escape;  and  it  is  the  writer's  belief  that  had  the  Indo- Javanese  pilgrims 
been  quarantined  by  the  Eygptian  authorities,  the  calamitous  epidemic  of 
cholera  of  1883  would  not  have  darkened  the  page  of  her  history. 

So  long  as  nations  neither  stamp  out  disease  within  their  territories 
nor  see  to  it  that  all  ships  are  clean  and  sail  from  clean  ports,  just  so  long 
it  will  be  necessary  to  maintain  a  quarantine  of  some  sort,  and  it  is  prolia- 
ble  that  inspection  stations  can  never  be  dispensed  Avith,  but  their  use  may 
in  coming  time  be  reversed,  that  is  for  the  inspection  of  outgoing  ships. 

The  recent  experience  of  Europe  has  not  tended  to  settle  the  question 
as  to  the  efficacy  of  quarantine,  although  the  principle  still  remains  as 
(juoted  from  Professor  Stille,  that  where  there  has  been  a  failure  it  is  due 
to  the  laxity  of  the  quarantine.  Tommasi-Crudeli  of  Milan,  Avriting  after 
the  cessation  of  the  recent  epidemic  in  Italy  says:  ''  Sea-quarantines  offer 
stronger  guarantees  than  land  quarantines,  but  may,  however,  prove  defi- 
cient for  three  reasons:  First,  liccause  the  duration  of  the  quarantine  in 
proportion  to  the  period  of  incubation  is  insufficient;  second,  because  dur- 
ing quarantine  the  disinfection  of  really  infected  objects  is  impracticable. 
It  is  not  sufficient  to  leave  infected  boxes  of  linen  half  exposed  to  a  chloridic 


THE  PRACTICE  OF  QUARANTINE.  347 

atmosphere;  the  essential  is  that  during  quarantine  there  be  thorough  and 
vigorous  disinfection;  tliird,  because,  notwithstanding,  all  governmental 
regulations,  even  sea  quarantines,  are  easy  to  violate.  He  proceeds:  "At 
Malta,  in  1865,  after  the  appearance  of  cholera  in  Alexandria.  Eg}'pt,  the 
Government  ordered  a  rigorous  quarantine,  but  it  was  violated  and  the 
epidemic  broke  out  violently.  Too  many  interests  prompt  its  violation,  and 
it  is  seldom  that  people,  as  did  the  Sicilians,  unite  in  silencing  such  inter- 
ests. In  Sicily,  in  18G5,  the  whole  population  advocated  a  quarantine  of 
seven  days  for  vessels  arriving  from  non-infected  ports,  and  of  absolute 
non-intercourse  with  infected  countries,  and  the  island  was  thus  guarded 
until  the  insurrection  of  September,  1866.  The  epidemic  appeared  the 
very  day  on  which  troops  sent  from  Naples,  where  cholera  was  raging,  ar- 
rived at  Palermo.  The  epidemic  spread  rapidly,  and  the  incident  sIioavs 
that  when  sustained  by  thej)opuJation,  sea  quarantine  is  efficacious." '  The 
Honorable  Philip  Carroll,  U.  S.  Consul  at  Palermo,  writing  to  Honorable 
"William  Hunter,  Second  Assistant  Secretary  of  State,  under  date  of  Febru- 
ary 9.  1885,  says:  "With  reference  to  the  non-appearance  of  cholera 
in  Palermo,  during  the  recent  epidemic,  in  places  almost  conterminous 
thereto,  the  general  belief  here  is  that  the  immunity  was  due  to  the  effective 
and  rigorous  quarantine  which  was  at  once  established  and  maintained 
until  some  time  after  it  Avas  suspended  in  other  places  and  ever  vestige  of 
the  disease  had  disappeared.  In  support  of  this  belief,  they  quote  the  epi- 
demics of  18G5  and  1873,  when  the  same  vigorous  measures  were  adopted 
and  maintained,  with  the  same  immunity  from  the  disease,  Avhereas  in  1866 
the  insurrectionists  broke  the  quarantine,  when  cholera  immediately  broke 
out  and  made  havoc  among  its  inhabitants.  From  personal  observation  I 
am  quite  sure  that  the  sanitary  condition  of  the  city  had  little  or  nothing 
to  do  with  its  escape  from  the  recent  contagion;  on  the  contrary,  there 
Avere  many  circumstances  and  conditions  which  in  this  resjiect  were  favor- 
able to  an  outbreak  of  the  disease." 

The  recent  sanitary  history  of  Sicily  cannot  fail  to  teach  a  salutary 
lesson  to  those  preaching  the  inefficacy  of  sea  quarantine.  The  quaran- 
tines of  Italy,  on  the  contrai-y,  Avere  inefficient.  Dr.  Mosso"  states: 
"•  When  I  asked  Dr.  Koch  what  he  thought  of  the  quarantines  in  operation 
in  Italy,  he  replied  to  me:  '  I  am  convinced  they  are  Avorth  nothing;  they 
are  half  measures  Avithout  real  results.'''' 

THE  PRACTICE    OF  QUAEANTDsE. 

A.  By  Sea. — The  practice  of  quarantine  is  without  uniformity,  scarcely 
any  tAvo  countries  conforming  to  the  same  regulations;  and,  as  pointed  out 
by  Dr.  John  S.  Billings,  U.  S.  A.,  "  Theoretically  (quarantines)  as  a  rule 
err  on  the  side  of  excessive  requirement;  practically  the  error  is  the  other 
AA'ay.  Xeither  in  America  nor  in  Europe  can  one  draAv  reliable  conclusions 
as  to  Avhat  is  actually  done  at  a  quarantine  establishment  from  its  printed 
regulations."  (Transac.  International  Medical  Congress,  Vol.,  IX.  page 
419,  London  1881.)  It  is  natural  that  diA-ersity  of  climate  and  differences 
of  season  should  modify  the  practice  of  quarantine  at  particular  ports,  but 
there  should  be  no  laxity  of  administration  at  any  time  or  anyAvhere.  The 
medical  insjjection  which  is  the  only  method  of  ascertaining  the  facts  re- 

'  The  italics  are  mine. — J.  B.  H. 

'^  Mosso,  Le  Preeauzione  centre  il  Colera  e  le  quarantene.  Reprint  from  XuoA'a 
Antologia,  \^ol.  xlvii.,  fuse,  xviii.  15  Settenibre,  1884. 


348  ASIATIC  CHOLERA. 

garding  the  sanitary  condition  of  passengers,  cargo,  crew  and  ship,  should 
be  everywhere  carried  on  in  the  same  Avay.  The  period  of  detention  may 
reasonably  vary  with  port  and  season,  but  the  inspection  should  be  always 
the  same. 

Carelessness  in  making  such  inspections  is  a  crime  and  should  be  so  con- 
sidered. Efficiency  depends  upon  the  honest ij,  fnifhful?wss  and  patriotism 
of  the  inspector.  'Xo  man  should  be  selected  "for  this  great  responsibility 
who  does  not  combine  with  the  necessary  technical  knowledge  these  three 
characteristics. 

The  following,  revised  from  an  article  by  the  writer, '  gives  an  account 
of  the  details  of  quarantine  management: 

A  quarantine  stsition  usually  consists  in  a  hospital  for  the  sick  (laza- 
retto, so  named  from  the  isolation  of  St.  Lazarus  on  account  of  leprosy, 
mat  de  Saint  Lazare);  a  boat,  usually  a  steam  vessel,  to  carry  the  boarding 
officer  and  supplies  for  the  station,  if  there  be  any  sick  found  on  board 
the  vessel  coming  into  port,  a  separate  boat  or  the  ship's  boat  should  take 
them  to  the  lazaretto;  and  quarters  for  attendants.  On  arrival  of  a  vessel 
at  the  quarantine,  she  is  boarded  by  an  inspecting  officer,  her  bill  of  health 
examined,  the  crew  and  passengers  mustered,  the  vessel  itself  inspected  in 
every  part  to  determine  whether  it  be  clean  or  foul.  At  this  day,  the  bill 
of  health  is  not  accepted  as  prima  facie  evidence  of  the  sanitary  condition 
of  the  vessel,  but  is  only  corroborative.  Even  if  it  be  stated  thereon  that 
the  port  from  which  the  vessel  last  sailed  was  free  from  infectious  disease, the 
inspector  trusts  to  his  OAvn  inspection  of  the  vessel  and  examination  of 
the  persons  on  board  and  the  cargo,  together  with  his  knowledge  of  the 
sanitary  condition  of  the  port  of  departure  to  determine  whether  or  not 
the  vessel  should  be  detained  in  quarantine.  If,  however,  the  vessel  is 
from  an  infected  port,  and  the  period  of  incubation  of  the  disease  has  not 
elapsed,  the  vessel  is  detained  in  quarantine  until  the  expiration  of  that 
time,  whether  there  be  sickness  on  board  or  not.  If  there  be  found  con- 
tagious sickness,  the  sick  are  removed  to  the  hospital,  the  bedding  and 
other  articles  in  their  state-rooms  or  berths  removed  and  destroyed,  and 
the  place  thoroughly  fumigated  with  the  fumes  of  burning  sulphur.  In 
case  the  vessel  is  discovered  to  be  foul  and  in  an  unsanitary  condition, 
whether  there  is  sickness  on  board  or  not,  the  vessel  is  detained  in  quar- 
antine for  the  purpose  of  cleansing  and  fumigation,  the  cargo  is  removed 
to  a  warehouse,  or  to  open  lighters,  the  bilge  AA-ater  pumped  out  and  all 
parts  of  the  vessel  fumigated.  The  hold  of  an  infected  vessel  should  be 
thoroughly  Avashed  out  l^efore  fumigation  Avith  solution  of  the  sulphate  of 
copper.  The  sulphate  of  iron  is  cheaper  and  nearly  as  efficacious.  Cor- 
rosive sublimate  solution  may  also  be  employed.  Whenever  necessary, 
the  Avood-Avork  should  be  repainted. 

For  the  treatment  of  the  cargo  as  Avell  as  the  vessel  much  yet  remains 
to  bring  the  practice  to  a  level  Avith  the  adA'anced  state  of  collateral  sciences. 
As  shown  by  Dr.  Joseph  Holt  of  Xcav  Orleans,  Ave  arc  still  pursuing  the 
practice  of  a  past  age  in  the  lack  of  improved  machinery.  An  invention 
has  recently  come  into  use  for  the  disinfection  of  rags  Avhich  makes  it 
possible  to  disinfect  them  in  a  bale.  The  fumes  of  burning  sulphur,  are 
driven  into  the  bale  through  holloAV,  perforated  scrcAvs.  Superheated 
steam  may  also  be  used,  and  is  in  fact  easier  of  application. 

1  Cyclopcedia  of  Political  Science,  Political  Economy  and  Political  Ilistoiy  of 
the  United  States,  edited  by  John  S.  Lalor,  Chicago,  1883. 


THE  PRACTICE  OF  QUARANTES^E.  349 

B.  By  land. — Land  quarantine  is  that  form  of  quarantine  whicli 
has  furnished  the  opponents  of  the  S3"stem  with  their  most  effective  argu- 
ments. If  rigorously  carried  out,  it  is  denounced  as  cruel  and  barbarous; 
if  loosely  enforced,  it  is  certainly  ineffective.  The  weight  of  medical 
opinion  at  this  day  is  theoretically  against  land  quarantines, '  but  practi- 
cally almost  every  country  establishes  an  inspection  system  on  its  frontier 
as  soon  as  the  introduction  of  an  epidemic  is  threatened.  In  the  United 
States  "  shotgun  "'  quarantines  always  follow  the  failure  of  a  State  or  the 
Government  to  establish  a  proper  quarantine,  and  as  one  of  the  elements  of 
land  quarantine,  and  as  well  as  a  means  of  allaying  excitement  and  pre- 
venting panic,  cordons  sanitaire  are  very  useful,  as  was  proved  during  the 
yellow  fever  epidemic  of  1882  in  Texas.  Sparsely  settled  countries  show 
the  usefulness  of  the  cordon  sanitaire  to  its  best  advantage;  indeed  the 
system  is  considered  impracticable  if  not  impossible  to  carry  out  where 
large  cities  are  concerned.  This,  however,  is  fallacious;  the  land  quaran- 
tine is  difficult  to  carry  out,  but  not  by  any  means  impossible.  A  land 
quarantine  is  simply  medical  inspection  of  travelers,  their  baggage,  the 
vehicles  of  transjoortation  and  the  freight  carried  thereon,  and  the  cordon 
sanitaire  simply  the  local  police.  This  duty  may  be  effectively  performed 
by  troops  or  by  carefully  picked  men  from  civil  life.  The  plan  followed 
in  Kussia  as  a  means  of  stamping  out  the  plague  will  appear  from  the 
following  account: 

"  The  Oriental  plague  made  its  appearance  in  the  district  above  Astra- 
khan, in  Russia,  about  the  middle  of  Xovember,  1878.  It  prevailed  along 
the  river  A'olga,  and  upon  its  islands.  The  center  of  the  maladv  was  in 
the  village  of  Wetljankaja,  with  a  population  of  some  seventeen  hundred 
inhabitants.  The  Governor  of  Astrakhan  telegraphed  to  the  Minister  of 
the  Interior  the  report  of  the  medical  supervisor  of  the  Cossack  forces  in 
the  district  of  Astrakhan,  Dr.  Depner.  A  few  cases  had  appeared  in 
the  previous  year,  but  the  disease  had  not  become  epidemic  until 
Xovember,  1878.  From  the  27th  of  Xovember  to  the  9tli  of  Decem- 
ber, out  of  one  hundred  sick  in  Wetljankaja  forty-three  died;  and  in 
less  than  a  month  two  hundred  and  seventy-three  persons  died  of  the  dis- 

'  The  following  may  prove  of  interest  in  this  connection: 

On  the  1st  of  Juij-,  1884,  the  Ministei*  of  Commerce  appointed  the  following- 
named  pei-sons  to  serve  as  a  cholera  commission  to  consider  tlie  measures  best 
adapted  to  restrain  the  ravages  of  the  epidemic  at  that  time  existmg-  at  ToiUon 
and  Mai-seilles.  The  commission  was  composed  of  MM.  Brouardel,  cliairnian, 
Pasteur,  Peter,  Proust,  Legouest,  Rochard,  Gallard,  Vallin,  and  Nicolas,  director 
of  internal  commerce.  Tlie  commission  pi-esented  its  report  to  the  Academy  of 
Medicine,  in  order  to  obtain  tlie  approval  of  that  body,  before  submitting  it  to  the 
Minister  of  Commerce.  Tlie  conclusions  of  tliis  report,  which  were  adopted  by 
the  Academy,  were  as  follows: ' 

1.  Land  quai-antines,  whatever  be  the  form  under  which  they  are  established, 
are  impracticable  in  France.  2.  The  methods  of  disinfection  imposed  upon 
ti-avelers  and  their  baggage  in  the  i-ailway  stations  are  inefficacious  and  illusory. 
3.  Posts  of  medical  surveillance  might  be  established  in  the  lai-ger  stations  along 
the  lines  of  railway  in  order  to  render  assistance  to  those  attacked  with  cholera, 
and  to  isolate  them  from  the  other  traveler.  4.  The  efficacious  measures  of 
preservation  are  those  which  each  one  ought  to  take  for  himself  and  his  house. 

The  duty  of  the  municipal  authorities  is  to  see  that  the  instructions  in  regard 
to  isolation  of  the  sick,  to  disinfection  of  linen,  clothes,  apartments,  etc.,  are  rigor- 
ously enfoi'ced,  and  that  the  precautions  of  private  and  general  hygiene  are 
executed  in  all  theu-  rigor. — E.  C.  W. 

' Brouardel;  Epid^mie  du  Choldra  k  Toulon  et  k  Marseilles,  Paris.    J.  B.Baillifere  et  Fils,  1884. 


350 


ASIATIC  CHOLERA. 


ease.  It  then  spread  from  Wetljankaja  to  the  surrounding  villages,  and 
was  declared  epidemic.  '  Dr.  Koch  and  six  army  surgeons  became  vic- 
tims to  the  epidemic,  the  priest  died,  the  Cossacks  who  attended  the  sick 
or  removed  the  dead  died;  almost  all  died  who  in  any  way  came  in  contact 
with  the  sick  or  dead.'  Dr.  Depner  then  arrived  at  the  conclusion  that 
the  only  means  for  suppressing  the  disease  was  quarantining;  and  on  the 
lltli  of  December,  Dr.  Depner,  with  Colonel  Preibanow,  instituted  meas- 
ures. He  could  not  prosecute  further  observations,  hoAvever,  for  he  him- 
self fell  sick  Avitli  the  plague.  These  facts  being  telegraphed  to  the  Em- 
peror of  llussia,  the  Imperial  Committee  of  Ministers  was  convened,  and 
the  following  rules  were  adopted,  which  received  the  imperial  sanction: 

"  1.  (a.)  The  inhabitants  of  the  colony  of  Wetljankaja  shall  be  trans- 
ferred and  distributed  as  shall  seem  best  after  a  careful  examination  of 
the  local  requirements,  the  limit  of  the  quarantine  not  to  be  overstepped. 


"  (b.)  The  appraisement  of  the  movable  and  immovable  jiroperty  de- 
stroyed by  fire,  as  likewise  the  fixing  of  the  indemnities  to  be  paid  to  the 
owners,  shall  be  reserved  for  a  special  commission,  under  the  presidency 
of  the  Governor  of  Astrakhan,  with  the  participation  of  members  of  the 
Cossack  administration  and  the  Ministry  of  the  Finances,  the  Ministry  of 
the  Domains,  and  the  Ministry  of  the  Interior,  according  to  regulations 
which  shall  be  prepared  on  the  spot  by  the  aforesaid  commission. 

"  (c.)  This  commission  shall  be  charged  Avith  the  execution  of  all  the 
measures  that  may  be  necessary  for  the  destruction  by  fire  of  the  colony 
of  Wetljankaja,  as  likewise  of  all  measures  necessary  to  supply  the  popu- 
lation transferred  from  that  colony  with  food,  underclothing,  and  warm 
garments;  to  j)rovide  for  the  treatment  of  the  sick,  etc. 

"  2.  That  the  acting  Minister  of  the  Interior  maybe  authorized  to  ex- 
tend the  measures  referred  to  concerning  the  colony  of  Wetljankaja  to 
other  villages,  as  Avell  as  to  isolated  buildings  everywhere,  to  such  extent 
as  shall  be  deemed  indispensable. 


THE  PRACTICE  OF  QUARANTINE.  35;^ 

"  3.  That  three  regiments  of  Cossacks  may  be  immediately  placed  at 
the  disposal  of  the  civil  administration  for  the  quarantine  service. 

"  4:.  That  all  outlays  necessary  for  the  execution  of  the  measures  above 
referred  to,  and  to  meet  the  expenses  of  all  measures  that  may  be  required 
by  the  present  epidemic,  may  be  charged  to  the  account  of  "the  imjjerial 
treasury.-' 

It  was  the  unanimous  conclusion  that  "  the  plan  of  burning  the  colony 
of  Wetljankaja  (the  center  of  the  infection)  is  proposed  after  a  thorough 
examination  of  the  question,  and  from  a  conviction  of  the  indispensable 
necessity  of  so  radical  a  measure  for  the  extirpation  of  the  disease  in  the 
locality  where  it  first  appeared — the  committee  having  subsequently  heard 
the  opinion  of  the  physicians  present,  both  with  regard  to  the  measure  in 
question,  and  in  general  in  relation  to  the  means  which  have  been  shown 
by  science  and  experience  to  be  best  adapted  to  put  a  stop  to  an  epidemic, 
and  to  prevent  it  from  spreading.'' 

In  addition  to  the  irregular  troops  mentioned  above,  bodies  of  infantry 
were  placed  at  the  disposal  of  the  civil  establishments,  and  unlimited 
credit  was  opened  to  meet  all  expenses  from  the  treasury.  His  Majesty 
the  Emperor  sent  a  special  commissioner  plenipotentiary.  A  commission 
was  appointed  to  act  in  the  matter,  composed  of  medical  specialists,  whose 
duty  it  was  to  study  the  subject  of  the  progress  of  the  epidemic,  and  the 
proper  means  of  stamping  it  out,  and  purifyiiig  the  localities  then  infected 
or  those  likely  to  become  so;  and  in  view  of  the  impression  produced  in 
foreign  countries  by  the  reports  of  the  plague,  they  should  furnish  to  this 
government  reliable  information  concerning  the  epidemic,  and  the  meas- 
ures adopted  against  it;  and  the  instructions  Avere  carried  out  as  al)ove 
outlined,  under  the  direction  of  Aide-de-Oamp  General  Count  Loris-Meli- 
kolf,  who  was  sent  to  the  infected  locality  with  the  rights  and  privileges 
of  a  temporary  governor-general.  On  the  arrival  of  Count  Loris-Melikoff, 
in  March,  1S79,  an  international  sanitary  council  was  held,  composed  of 
the  most  distinguished  sanitarians  of  Europe,  Professors  Hirscli,  Besia- 
detsky,  Cabiadis,  Petrisco  and  Eichwald.  By  the  advice  of  the  Inter- 
national Council,  a  general  sanitary  cordon  was  established  all  round  the 
province  of  Astrakhan,  with  the  object  of  protecting  Kussia  and  neighbor- 
ing countries  of  the  empire,  and  Professor  Eichwald  advised  that  the  sani- 
tary cordon  should  be  maintained  around  the  infected  region  until  the  2d 
of  May.  These  measures  were  entirely  successful,  and  the  plague  did  not 
spread  to  any  other  place  outside  of  the  originally  infected  district,  nor 
has  it  reappeared. 

In  the  United  States  a  land  quarantine  was  established  under  my  di- 
rection for  the  prevention  of  the  spread  of  yellow  fever  in  Texas  in  the 
summer  of  1882. 

A  serious  epidemic  of  yellow  fever  broke  out  in  Bagdad,  Tampico,  and 
Matamoros,  Mexico,  and  soon  spread  to  Brownsville,  in  the  State  of  Texas. 
There  were  in  a  short  time,  out  of  a  city  of  some  5,000  inhabitants,  between 
five  and  six  hundred  persons  sick  of  yellow  fever.  A  general  panic  pre- 
vailed througliout  southwestern  Texas,  and  refugees  .were  leaving  that 
part  of  the  State  in  great  numbers,  as  it  was  believed  the  infection  would 
rapidly  and  certainly  extend  to  the  surrounding  country.  Under  these 
circumstances,  an  appropriation  of  1100,000  having  been  placed  at  the  dis- 
posal of  the  Treasury  Department  to  prevent  the  spread  of  epidemics,  by 
the  President,  the  Governor  of  the  State  of  Texas  applied  to  the  Secretary 
of  the  Treasury  for  assistance  from  the  general  government;  and,  as  the  exact 


352 


ASIATIC  CHOLERA. 


area  of  tlie  infected  region  was  undetermined,  at  my  suggestion  a  cordon  was 
immediately  established  from  Corpus  Christi,  on  the  Gulf,  to  Laredo,  on  the 
Rio  Grande,  along  the  line  of  the  Texas  and  Mexican  Kailway.  Ko  person 
was  allowed  to  pass  this  cordon  until  after  ten  days'  detention  at  some  one 
of  the  quarantine  stations  (represented  by  flags  upon  the  accompanying 
ma])),  that  length  of  time  being  considered  necessary  to  determine  whether 
or  not  the  particular  person  would  be  attacked  with  yellow  fever.  Baggage 
was  not  allowed  to  cross  the  line  upon  any  pretext.  A  hospital  was  estab- 
lished in  the  city  of  Brownsville,  a  dispensary  opened,  and  experienced 


physicians  and  nurses  sent  there,  who  were  constantly  employed  in  the 
treatment  of  the  poor,  and  all  persons  unable  to  pay  were  treated  and 
cared  for  at  the  public  expense.  These  physicians  also  aided  the  health 
authorities  of  the  city  in  carrying  out  sanitary  measures,  including  the 
fumigation  of  houses. 

As  soon  as  practicable  after  opening  the  hospital,  an  inner  protective 
cordon  Avas  established,  thirty  miles  from  Brownsville,  the  original  cordon 
having  been  one  hundred  and  eighty  miles  distant.  Perfect  liberty  was 
allowed  to  the  inhabitants  of  the  infected  city  to  leave  at  any  time,  and 
they  were  encouraged  to  scatter  in  camps;   but  they  were  not  allowed  to 


THE  PRACTICE  OF  QUARANTINE.  353 

cross  the  cordon  until  after  personal  detention  of  ten  days,  and  fumigation 
of  their  wearing  apparel;  and,  as  in  the  case  of  the  outer  cordon,  the 
crossing  of  baggage  was  positively  interdicted.  It  was  intended  to  remove 
the  upper  cordon  between  Laredo  and  Corpus  Christi  within  ten  days 
after  the  formation  of  the  inner  o-ne,  which  extended  from  Santa  Maria, 
on  the  Eio  Grande,  to  the  mouth  of  the  Sol  Colorado;  but  it  was  retained 
for  several  days  longer,  as  certain  of  the  refugees  who  had  left  Brownsville 
prior  to  the  establishment  of  the  Colorado  cordon  developed  yellow  fever. 
They  were  quarantined  in  the  camps  where  they  were,  and  their  infected 
bedding  and  baggage  burned.  The  fever  continued  its  spread  and  devas- 
tation on  the  Mexican  side  of  the  Eio  Grande,  and  Keynosa,  Camargo, 
Mier  and  Guerrero  successively  became  infected.  It  was  then  found 
necessary  to  protect  the  entire  line  of  the  Rio  Grande,  from  Laredo  to 
Santa  Maria,  a  distance  of  nearly  five  hundred  miles,  by  a  cordon.  The 
upper  cordon,  from  Laredo  to  Corpus  Christi,  was  then  removed,  and  the 
line  reestablished  along  the  Rio  Grande,  and  the  crossing-places  care- 
fully guarded;  and,  although  the  towns  in  Mexico  were  greatly  "devastated 
by  the  disease,  there  was  no  extension  of  it  in  Texas;  on  the  contrary,  it 
was  confined  to  the  limited  district  where  it  first  appeared,  bounded  by 
the  Colorado  cordon  on  the  one  hand  and  the  Gulf  of  Mexico  upon  the 
other.  The  Mexicans,  seeing  the  good  effects  of  the  sanitary  cordon  in 
the  United  States,  followed  the  example,  and  established  quarantine 
stations  in  Mexico,  guarding  against  the  infected  towns;  and  there,  too, 
the  quarantine  proved  successful,  and  arrested  the  spread  of  the  disease. 
The  Governor,  the  State  Health  Officer,  and  the  State  officers  generally, 
assisted  the  work  of  the  government  by  all  the  means  at  their  command. 

In  July  of  the  same  year  a  few  cases  of  yellow  fever  appeared  in  Pen- 
sacola,  Fla.,  and  later  the  disease  became  epidemic,  and,  as  in  Texas,  a 
general  panic  prevailed.  The  villages  and  towns  surrounding  Pensacola 
established  a  rigid  quarantine  against  it,  no  person  from  that  city  being 
allowed  to  enter  except  after  ]3roper  detention  and  fumigation.  In  conse- 
quence of  this,  the  towns  that  had  thus  protected  themselves  by  the  quar- 
antine were  not  infected,  and  the  disease  did  not  spread,  while  the  places 
adjoining  that  did  not  quarantine  against  Pensacola  had  the  fever.  The 
Government  also  protected  its  navy-yard,  which  joins  the  city  of  Pensacola, 
by  means  of  a  sanitary  cordon  and  non-intercourse  with  the  city  during 
the  prevalence  of  the  epidemic,  and  it,  too,  escaped.  ^ 

It  is  as  unfair  and  unscientific  to  denounce  land  quarantines  because 
the  majority  of  them  have  been  inefficient  as  it  is  to  denounce  sea  quaran- 
tines on  similar  grounds,  but  this  in  fact  seems  to  be  the  real  reason  for 
the  opposition.  Professor  Tommasi-Crudeli,  in  a  recent  article,  says: 
''How  proceed,  for  example,  in  circumstances  like  the  present, when  cholera 
is  on  the  European  continent  at  Toulon  and  Marseilles?  Think  you 
that  if  a  panicky  terror  seized  the  population  of  the  stricken  places,  es- 
pecially of  our  Italian  colonies,  as  it  has,  in  fact,  it  would  be  possible  to 
forbid  the  return  of  the  fugitives  to  Italy  by  the  issuance  of  sanitary  ordi- 
nances? If  we  barred  the  'Twenty-mile  road,' they  would  turn  to  the 
Cenisepass;  if  we  blockaded  the  latter  they  would  force  the  Gothardway; 
could  we  close  every  railroad  line  and  every  Alpine  wheel  route,  they 
would  improvise  a  hundred  footpaths  through  the  mountains  to  find  a  way 

'  From  an  article  by  tlie  writer  in  Appleton's  Annual  CyclopEedia,  1883,  pp. 
291-294, 

23 


354  ASIATIC  CHOLERA. 

to  return  home.  We  see  something  similar  in  contraband  frontier  traffic. 
Two  revenue  cordon's,  one  Italian  and  one  French,  have  been  organized 
and  maintained  for  united  efforts  to  repress  contrabandage  and  for  the  pro- 
tection of  material  interests  jeopardized  by  it,  but  in  spite  of  them  Italian 
bands  continually  enter  France,  and  French  bands  enter  Italy." 

This  argument  would  seem  to  indicate  that  the  learned  professor  would 
abolish  the  revenue  laws  because  of  the  inefficient  manner  in  which  they 
are  enforced.  A  land  quarantine  when  properly  conducted  is  not  at  the 
present  time  an  impassable  barrier.  At  the  cordon,  refugees  are  simply 
detained  for  inspection  and  to  await  the  period  of  incubation  of  the  disease; 
with  proper  refuge  stations  along  the  line,  there  is  no  difficulty  in  provid- 
ing suitable  accommodations.  The  hospital  tents  used  by  the  United  States 
can  be  made  entirely  comfortable.  At  the  last  meeting  of  the  "Missis- 
sippi Valley  Sanitary  Council,"  held  at  New  Orleans,  March  11th,  1885, 
it  was  agreed  that  sleeping-cars  should  not  be  allowed  to  pass  inspection 
stations  when  coming  from  any  infected  place,  and  such  station  should  be 
established  at  a  point  not  less  than  fifty  nor  more  than  seventy-five  miles 
from  the  infected  place.  At  this  station  the  well  passengers  should  be 
transferred,  and  those  suffering  from  real  or  suspected  contagious  disease 
shall  be  detained  at  a  hospital.  In  regard  to  baggage,  it  is  provided  that 
none  shall  leave  an  infected  city  without  thorough  disinfection  by  means 
of  bichloride  of  mercury.  This  system  of  inspection  is  substantially 
that  adopted  by  Holland  so  satisfactorily  during  the  recent  epidemic.  The 
Dutch  required  that  all  persons  passing  the  line  should  leave  their  address, 
find  all  soiled  clothing  was  left  behind  to  be  disinfected. 

C.  In  Foreign  Ports. — In  the  subdivision  on  international  noti- 
fication the  general  necessity  of  having  a  medical  attache  at  each  consular 
district  Avas  mentioned  in  connection  with  duty  in  regard  to  bills  of  health, 
etc. ;  but  when  an  actual  epidemic  appears  in  any  district  having  direct  or 
indirect  commerce  with  the  United  States,  the  necessity  for  the  employment 
of  such  an  officer  becomes  more  imperative,  because  the  responsibility  is 
then  placed  upon  him  of  j)reventing  so  far  as  he  may  be  able,  the  embark- 
a.tion  of  sick  emigrants,  or  of  infected  baggage  or  merchandise.  The  medi- 
cal inspection  of  each  passenger,  and  tracing  up  his  record,  and  noting  the 
character  and  condition  of  the  baggage,  was  the  somewhat  onerous  duty 
the  Government  2:>laced  upon  its  medical  inspectors  abroad  during  the  re- 
cent outbreak  of  cholera  in  Europe.  At  every  European  port  whence  ves- 
sels departed  for  the  United  States  this  system  was  faithfully  carried  out. 
One  steamship  line  protested  that  their  surgeon  made  an  inspection  of 
emigrants  and  their  baggage,  and  that  there  Avas  great  and  unnecessary 
delay  by  their  being  obliged  to  undergo  the  special  rigid  inspection;  and 
in  many  cases  they  were  sent  back  by  the  inspector  for  disinfection,  but 
the  responsibility  imposed  upon  the  Government  was  too  deeply  felt  to 
allow  any  relaxation  of  the  foreign  inspections,  until  the  subsidence  and 
disappearance  of  the  epidemic,  and  during  the  past  year  not  a  single  case 
of  cholera  was  received  at  any  quarantine  station  of  the  United  States. 


MUNICIPAL  MEASURES.  355 


CHAPTEE  XLI. 

MUNICIPAL    MEASURES  AND  PERSONAL  PROPHYLAXIS. 

The  Municipal  Measures  to  be  adopted  for  the  prevention  of 
cholera,  in  addition  to  those  of  quarantine  already  described,  consist  of 
all  those  measures  which  favor  cleanliness  and  thus  counteract  a  lodgment 
of  the  disease  germs,  and  those  necessary  should  the  disease  nevertheless 
be  imported.  The  proper  municipal  health  authority  should  inform  the 
public — 

First,  That  there  is  no  occasion  for  alarm  if  the  regulations  are  com- 
plied with;  and. 

Second,  The  regulations  should  be  published  in  such  manner  that  every 
householder  may  receive  notification  of  the  things  required  of  him.  With 
the  carrying  out  of  the  regulations,  the  police  and  health  departments 
of  cities  should  be  jointly  charged.  The  city,  for  convenience,  should  be 
divided  iuto  sanitary  districts  and  the  sanitary  officer  held  responsible  for 
the  condition  of  each  district.  A  special  hospital,  or  hospitals,  should  be 
provided,  and,  in  connection  therewith  a  public  laundry  established.  The 
most  careful  cleanliness  should  be  everywhere  rigidly  enforced,  all  dark 
and  damp  places  thoroughly  disinfected  and  drains  and  sewers  systemati- 
cally flushed,  and  house  inspection  should  be  made  often  enough  by  the 
sanitary  inspector  to  insure  that  their  condition  does  not  become  worse 
from  neglect.  Congregations  of  the  people  in  times  of  epidemic  should 
be  avoided.  Great  crowds  should  not  be  allowed  to  form  in  any  portion 
of  the  city.  Should  cholera  break  out  in  any  house,  the  sick  should  be 
removed,  if  possible,  to  the  special  hospital,  the  house  itself  thoroughly 
disinfected,  all  the  interior  hangings,  carpets  and  the  like  reinoved  for 
disinfection  by  superheated  steam.  Physicians,  and  all  other  persons 
having  knowledge  of  a  case  of  cholera,  should,  under  penalty,  be  required 
to  immediately  inform  the  nearest  policeman,  through  whom  the  fact  would 
be  made  known  in  the  speediest  manner  to  the  proper  authority.  Special 
hospitals  for  cholera  patients  were  found  to  be  of  great  advantage  during 
the  recent  outbreak  of  cholera  in  Europe,  and  although,  as  at  Marseilles, 
the  mortality  in  them  seemed  a  little  higher  than  in  the  city  outside,  yet 
it  is  doubtless  due  to  the  fact  of  the  advanced  stage  of  the  disease  when 
the  patients  are  admitted,  for  mild  cases  rarely  find  their  way  to  the  hos- 
pital no  matter  how  stringent  the  regulation.  In  Boston,  in  the  epidemic 
of  1849,  a  cholera  hospital  was  improvised,  and  patients  were  sent  there  by 
the  district  inspectors.  The  city  physician  was  placed  in  charge,  and  the 
hospital  was  considered  to  have  been  a  valuable  adjunct  to  the  means  of 
prevention  of  the  spread  of  the  disease. 

Of  the  public  laundries,  there  is  a  baseless  fear  that  they  may  become 


356 


ASIATIC  CHOLERA. 


centers  for  the  propagation  of  the  disease,  but  Avhen  it  is  considered  that 
the  laundry,  if  riglitly  managed,  is  constantly  under  the  eye  of  an  inspector, 
who  is  responsible  for  carrying  out  the  sanitary  regulations,  it  is  at  once 
seen  that  such  fear  is  without  reason.  Tommasi-Crudeli,  who  was  the  direc- 
tor of  the  Public  Health  in  Palermo  in  ISGG,  says  that  in  managing  the  muni- 
cipal laundry  "the  carts  made  the  rounds  and  collected  all  the  infected 
clothing,  which  as  soon  as  brought  was  immersed  in  a  solution  of  chloride 
of  lime;  we  laundried  for  the  poor  gratis,  but  could  only  manage  the 
Avashing  for  public  institutions,  as  the  citizens  of  the  town,  fearing  conta- 
gion, refused  to  send  their  clothing  to  us.  The  result  was  that  of  my  em- 
ployees and  of  my  laundresses  not  one  took  cholera,  while  eleven  laun- 
dresses washing  in  the  usual  manner  died.-" 

The  instructions  of  the  French  Minister  of  Commerce  of  July,  1884, 
were  full  and  explicit  upon  the  method  of  disposal  of  infected  linen  and 
clothing,  and  preventive  measures  generally. 

Body  linen  soiled  by  dejections,  before  leaving  the  bedchamber, 
were  required  to  be  plunged  in  a  solution  of  the  "liqueur  bleu"' 
for  a  period  of  half  an  hour,  then  plunged  in  boiling  water  before  un- 
dergoing the  ordinary  washing.  All  clothing  suitable  for  washing  was 
required  to  be  treated  as  above,  but  clothing  that  could  not  be  washed 
was  submitted  to  the  fumes  of  burning  sulphur,  burning  not  less  than  30 
grams  of  flowers  of  sulphur  for  each  cubic  foot  of  air  space  in  the  cabinet 
or  box  where  the  clothing  was  suspended,  having  previously  rendered  the 
air  humid.  But  where  the  clothing  was  much  soiled,  by  dejections  or 
vomit,  it  was  burned. 

As  to  the  bedchambers  of  the  persons  sick  of  cholera,  the  carpet  was 
immediately  washed  by  the  aid  of  a  brush  with  the  "solution  blue"  or 
with  chloride  of  lime,  and  the  walls  also  treated  in  the  same  way.  The 
room  was  also  required  to  be  fumigated  with  the  fumes  of  burning  sul- 
phur as  soon  as  the  patients  were  removed.  Twice  daily  the  water-closets 
or  chamber  vessels  were  washed  with  the  solution  blue,  followed  by  a  satu- 
rated solution  of  the  chloride  of  lime.  The  infected  house  was  placed  in 
charge  of  a  sanitary  inspector  and  the  regulations  strictly  enforced,  the 
house  itself  being  quarantined  for  twenty-four  hours  from  the  disappear- 
ance of  the  case  and  the  completion  of  the  fumigation.  Disinfection 
materials  were  provided  free  and  distributed  by  the  police,  and  no  patient 
with  cholera  was  allowed  to  remain  at  a  hotel,  but  was  sent  immediately 
to  the  special  hospital  in  an  ambulance  kept  especially  for  these  cases. 
The  disinfecting  fluid  recommended  for  general  use  in  immediately  disin- 
fecting the  vomited  matters  and  the  dejections  was  a  solution  of  50  grams 
each,  in  a  litre  of  water,  of  chloride  of  zinc,  sulphate  of  copper  and  sul- 
phate of  zinc. 

The  proper  sanitary  officer  should  cause  regular  and  frequent  examina- 
tions to  be  made  of  the  drinking  water  of  the  city,  and  any  householder 
depending  upon  a  well  or  cistern  for  water  supply  should  have  the  privi- 
lege of  requesting  a  statement  of  the  healthfulness  of  the  water. 

Personal  Prophylaxis. — The  individual  can  do  much  toward  protect- 
ing himself  from  an  attack  of  cholera,  and  in  so  doing,  he  is  at  the  same 
time  doing  much  to  prevent  the  spread  of  the  disease,  for  each  single 
case  may  become  a  separate  center  for  the  origin  of  new  cases. 

Fear  should  be  met  by  fortitude,  courage  and  carefulness;  panic  itself 

'  Tills  liquid  is  made  as  follows:  Sulphate  of  copper,  50  grams;  water,  1  litre. 


PERSONAL  PROPHYLAXIS.  357 

is  conducive  to  the  onset  of  an  epidemic  disease,  by  rendering  the  system 
less  able  to  resist  the  epidemic  influence.  There  is  harm  in  sending 
patients  to  country  districts  where  the  drinking  water  is  derived  from 
wells,  which  in  a  majority  of  cases  suffer  more  or  less  from  infiltration  of 
organic  matter  from  a  privy  vault,  too  often  near  by  the  well  or  the  stable. 
So  it  is  better  to  advise  patients  in  comfortable  homes  to  stand  their  ground, 
live  as  usual,  to  be  temperate,  to  dress  warmly,  to  avoid  overfeeding  on 
the  one  hand,  or  starvation  on  the  other,  to  eat  regularly,  and  take  regular 
and  sufficient  sleep,  to  keep  away  from  promiscuous  crowds,  to  refuse  to 
admit  any  person  from  an  infected  house  or  district,  to  take  no  article  of" 
any  sort  from  an  infected  house,  and  to  drink  boiled  water. 

Chamber  vessels  should  be  disinfected  before  emptying  them,  and  the 
ordinary  water-closets  should  be  disinfected  twice  daily  during  the  prev- 
alence of  an  epidemic. 

It  is  advised  that  all  funerals  be  privately  conducted  at  such  times, 
and  in  no  case  is  it  allowable  to  attend  the  funeral  of  choleraic  victims. 

If  sickness  occur,  at  once  call  a  physician  in  whom  you  have  confidence, 
and  in  no  case  trust  advertised  "  cholera  preventives,"  however  much 
lauded. 


SEOTIOI^    III. 


CHOLERA  HYGIENE  AS  APPLIED  TO  MILITARY 

LIFE. 


BY 

ELY    McCLELLAN,    M.D., 

MAJOR  AXD   SURGEON  U.    S.    AR]«Y. 


CHOLERA  HYGIENE  IN  CAIUPS.  ^Ql 


CHAPTER  XLIL 

CHOLERA  HYGIENE  AS  APPLIED  TO  MILITARY  LIFE. 

The  hygiene  of  permanent  military  stations  differs  in  no  essential  re- 
spect from  that  which  applies  to  life  in  isolated  dwellings  and  tenement 
honses. 

Enlisted  men  are  fnrnished  with  clothing,  food  and  shelter  by  the 
general  government.  That  these  three  requisites  of  life  are  properly  pro- 
vided, and  that  no  one  is  deprived  of  his  portion  of  them,  is  the  duty  and 
constant  care  of  commanding  officers.  Enlisted  men  when  sick  and  un- 
able to  perform  duty  are  entitled  to  the  professional  care  of  a  medical 
officer,  who  has  under  his  charge  a  hospital  most  abundantly  supplied  with 
all  that  is  necessary  for  the  welfare  of  the  men  of  the  command. 

It  is  the  duty  of  the  commanding  officer  of  a  post,  and  of  the  officers 
immediately  in  command  of  troops,  to  see  that  each  enlisted  man  is  pro- 
tected in  the  receipt  of  all  bounty  from  the  government,  and  that  he 
renders  the  full  service  in  return.  It  is  the  duty  of  the  medical  officer  to 
guard  the  public  health  of  the  command;  to  preserve  the  hygiene  of  the 
post  at  the  highest  available  point,  and  to  cause,  so  far  as  may  be  in  his 
power,  the  destruction  of  what  Sternberg  has  so  aptly  termed  "  our  in- 
visible foes." 

A  permanent  military  post  should  afford  an  example  of  cleanliness  in 
all  things.  Nothing  should  be  permitted  to  remain  in  or  around  barracks 
or  other  buildings  which  may  be  prejudicial  to  health.  Sewer  connections, 
where  they  enter  buildings,  should  be  trapped  and  ventilated.  Conven- 
iences which  require  sewer  connections  should  be  reduced  to  a  minimum. 
Dormitories  should  be  freely  ventilated,  well  lighted,  and  during  the  cold 
months  properly  warmed.  Water-closets  and  urinals  should  under  no 
circumstances  be  permitted  under  barrack  roofs.  Drains  and  sewers 
should  be  sufficiently  often  flushed  to  secure  a  removal  of  all  debris  de- 
posited in  them.  A  frequent  and  lavish  use  of  disinfectants  should  be 
made.  The  quarters  occupied  by  officers  should  be  subjected  to  the  same 
careful  supervision  as  is  bestowed  upon  the  habitations  of  enlisted  men. 

The  water  supply  of  a  garrison  should  be  constantly  a  subject  of  ob- 
servation. Water  should  he  had  from  the  very  best  obtainable  source. 
The  condition  of  supply  pipes  should  be  an  object  of  constant  care.  When 
necessity  compels  the  use  of  water  from  cisterns  or  wells,  they  should  be 
kept  in  the  most  perfect  order,  and  the  greatest  care  should  be  had  to  avoid 
the  introduction  of  any  surface  washings.  When  there  is  the  least  sus- 
picion as  to  the  purity  of  the  water  supply,  it  should  always  be  boiled  and 
filtered  before  use,  and  all  members  of  a  command  should  be  enjoined  to 
use  only  water  so  prepared. 


362 


ASIATIC  CHOLERA. 


Whenever  it  is  practicable,  water-closets  sliould  be  provided  for  the  use 
of  all  at  a  military  post:  they  should  be  connected  Avitli  the  system  of 
sewers  which  should  empty  in  such  uosition  as  will  in  no  way  interfe^-e 
Avith  the  public  health. 

When  it  is  impracticable  to  employ  water-closets,  privy  vaults  should 
be  constructed  in  such  positions  as  to  secure  isolation.  These  vaults  should 
be  so  cemented  as  to  prevent  leakage,  be  frequently  subjected  to  the  action 
of  disinfectants,  and  at  short  periods  emptied  of  their  contents.  The  dis- 
position of  the  debris  from  such  vaults  should  be  a  matter  of  careful  solici- 
tude. The  lines  of  natural  drainage  around  a  post  should  be  always  a 
matter  of  care.  They  should  be  kept  constantly  free  and  unobstructed 
throughout  their  length. 

The  ration  of  the  enlisted  man  in  the  U.  S.  Army  is  most  liberal — it 
is  the  endeavor  of  officers  charged  Avith  such  supplies  to  furnish  articles 
only  of  superior  quality.  The  greatest  care  should  be  observed  in  the 
preparation  of  food  in  all  company  kitchens. 

The  clothing  of  a  soldier  is  amply  sufficient  for  all  his  requirements. 
In  no  other  army,  by  no  other  nation,  are  enlisted  men  more  perfectly 
cared  for,  and  the  American  soldier  is  furnished  with  luxuries  unknown 
to  soldiers  in  other  armies  and  to  the  majority  of  the  working  classes  in 
any  community. 

The  chief  causes  of  sickness  and  mortality  among  troops  are  to  be 
found  more  in  the  individual  habits  of  soldiers  than  in  their  surroundings. 

Whenever  an  epidemic  of  cholera  or  yelloAV  fever  occurs  in  the  vicinity 
of  a  military  post,  it  is  well  to  cause  the  removal  of  troops  to  such  position 
as  will  free  them  from  immediate  contact  with  the  disease.  The  rules  ad- 
vanced by  Niemeyer,  governing  such  circumstances,  are  always  good: 
"  Start  soon  enough.^'  "  Go  as  far  as  possible."  "  Do  not  return  untihthe 
last  trace  of  the  disease  has  disappeared."  Circumstances,  however,  Avill, 
especially  in  cholera  epidemics,  conspire  to  prevent  the  abandonment  of  a 
military  post.  At  such  a  time  a  strict  system  of  non-intercourse  with  in- 
fected or  even  suspected  localities  must  lae  maintained.  All  enlisted  men 
should  be  rigidly  confined  to  the  limits  of  the  military  reservation.  A 
camp  of  observation  should  be  established,  in  which  all  recruits  or  soldiers 
received  from  without  should  be  placed.  A  watch  should  be  kept  upon 
privies,  and  any  man  obliged  to  make  use  of  them  more  than  once  in 
twenty-four  hours  should  be  taken  under  observation  and  all  subsequent 
dejections  be  made  in  such  vessels  as  will  allow  his  condition  to  be  ascer- 
tained by  inspection.  No  enlisted  man  should  be  permitted  to  eat,  drink, 
or  sleep  outside  his  proper  quarters. 

While  it  is  advisable  for  all  persons  to  be  careful  in  their  diet,  and 
rigidly  to  avoid  all  articles  of  food  that  are  known  to  be  indigestible,  it  is 
also  necessary  not  to  occasion  too  sadden  and  radical  a  change.  Excesses 
of  all  kinds  should  be  avoided;  the  digestive  apparatus  should  be  encouraged 
to  the  performance  of  its  duty  by  the  presence  of  good,  well-prepared, 
wholesome  food.  Wine,  brandy,  and  malt  liquors  may  not  only  be  allowed, 
but  when  used  in  moderation  are  extremely  useful  in  averting  those  de- 
bilitating influences  Avliich  so  often  prevent  the  system  from  rei^clling 
disease;  but  their  use  should  be  positively  interdicted  whenever  undue 
stimulation  results. 

It  is  a  Avell-established  fact  that  when  the  digestive  organs  of  an  indi- 
vidual are  in  a  normal  condition  cholera  is  rarely  developed,  but  those 
whose  digestion  is  disturbed  readily  fall  victims  to  the  disease.     Experience 


CHOLERA   HYGIENE  AS   APPLIED   TO   MILITARY   LIFE.         3(33 

has  shown  that  a  debauch  predisposes  to  cholera  whenever  the  disease  is 
epidemic;  and  3'et  all  drunkards  in  a  cholera-infected  community  do  not 
take  the  disease.  Exceptions  simply  prove  the  rule.  Water  being  the 
vehicle  by  which  cholera  is  most  actively  distributed,  should,  before  being 
taken  for  any  domestic  use,  be  boiled  (and  ebullition  maintained  for  at 
least  thirty  minutes),  and  when  cool  passed  through  a  filter. 

The  surveillance  exercised  should  be  constant  and  far-reaching.  A 
case  of  cholera  occurring  within  the  limits  of  any  military  command  should 
lead  to  the  adoption  of  immediate  and  active  measures  to  ,stainp  out  the 
disease.  The  patient  should  be  at  once  placed  in  a  comfortable  but  iso- 
lated position.  Everything  belonging  to  him  and  which  he  has  had  in 
use  before  coming  into  the  hands  of  the  medical  officer,  as  well  as  every 
place  at  which  he  is  known  to  have  been  present  since  the  inception  of  the 
disease,  should  be  disinfected.  All  his  excreta  (vomit  and  dejections)  should 
be  received  in  vessels  properly  prepared.  The  surface  of  his  body  should 
be  occasionally  bathed  in  the  disinfecting  solution;  and  in  a  fluid  of  the 
same  character,  the  hands  of  attendants  and  the  various  utensils  employed 
about  the  case  should  be  frequently  washed.  When  access  can  be  had  to 
a  perfected  line  of  sewers  which  empty  into  a  rapidly  flowing  stream,  the 
various  fluids  (largely  mixed  with  disinfectant)  may  be  thrown  into  the 
sewer;  but  where  such  sewer  at  any  portion  of  its  course  has  a  cesspool  as 
the  recipient  of  its  contents,  then  deep  and  narrow  pits  should  be  dug,  and 
into  them  the  fluids  should  be  emptied.  Everything  belonging  to  and  in 
use  by  a  cholera  patient  should  be  thoroughly  disinfected.  If  articles  of 
clothing  or  bedding  are  to  be  destroyed  by  fire,  they  must  first  he  rendered 
inert  hij disinfection,'^  then  hiLr')ied.  Should  it  be  necessary  to  bury  the  ex- 
creta, the  bottom  of  the  pit  before  recommended  should  be  covered  with 
crystals  of  sulphate  of  iron  and  chloride  of  lime  in  bulk;  and  upon  this 
mass  the  disinfected  fluids  should  be  thrown.  Each  time  a  bucket  of  the 
latter  is  emptied  a  sufficient  quantity  of  fresh  earth  should  be  thrown 
upon  it,  and  before  final  closing  of  the  pit  a  solution  of  sulphuric  acid  in 
the  proportion  of  four  ounces  to  a  quart  of  water  should  be  placed  upon 
the  mass.  Then  the  pit  should  be  securely  covered  with  earth  closely 
packed  and  raised  some  inches  above  the  surface  of  the  surrounding  ground. 
It  is  very  important  to  remember  that  all  the  dejecta  of  a  cholera  case 
contain  the  seeds  of  the  disease,  and  that  the  infectious  principle  is  not 
confined  to  the  rice-water  passages  alone.  It  is  a  matter  worthy  of  careful 
consideration  whether  the  passages  before  and  after  the  stage  of  rice-water 
are  not  the  most  virulent.  They  should  he  treated  as  if  they  were.  In 
these  latter  days  long  and  exhausting  marches  of  troops  but  seldom  occur. 
In  changing  station  the  services  of  common  carriers  are  most  frequently 
called  into  requisition,  and,  of  these,  railroad  lines  have  absorbed  the 
traffic  almost  to  the  exclusion  of  water-transportation.  In  each  cholera 
epidemic  which  has  visited  the  United  States,  steamboats  were  the  most 
active  agents  in  distributing  the  disease  to  moving  bodies  of  troops,  and 
of  introducing  the  disease  into  permanently  garrisoned  posts.  Formerly 
bodies  of  troops  destined  for  Texas,  California,  or  the  Northwest  Terri- 
tories made  the  greater  portion  of  their  journeys  by  water  transportation, 
and  the  long  cholera  epidemic  from  which  the  army  suffered  from  1848  to 
185  G  was  undoubtedly  due  to  their  constant  conveyance  on  the  Missis- 
sippi, Ohio  and  Missouri  river  steamboats. 

'  See  preceding  section. 


3g4  ASIATIC  CHOLERA. 

But  a  few  years  ago  the  Missouri  river  was  the  boundary  line  of  civili- 
zation. From  the  river  posts  to  those  on  the  extreme  frontier,  long  and 
tedious  marches  were  made,  over  territory  where  now  great  trunk  lines  of 
railroad  whirl  troops  in  as  many  days  as  formerly  would  have  required 
months. 

But  a  few  years  ago  the  transportation  of  subsistence  stores,  clothing, 
and  camp  equipage  was  accomplished  only  by  wagon  trains.  Sick  teamsters 
and  other  train-employees  not  infrequently  Avere  carried  on  the  wagons 
containing  clothing  or  food.  These  trains  were  often  months  upon  the 
road,  were  constantly  halted  upon  old  and  often-used  camp  grounds,  and 
were  frequently  the  carriers  of  infectious  diseases.  Now,  the  same  class 
of  articles  securely  packed  in  freight  cars  are  delivered  at  or  comparatively 
near  most  army  posts,  and  the  transportation  used  in  the  absolute  de- 
livery at  the  post  storehouses  is  that  which  is  under  the  constant  suj)er- 
vision  of  the  military  authorities. 

The  advantage  gained  to  the  army  by  this  new  system  is  very  great. 
Healthy  recruits  are  no  longer  sent  from  healthy  depots  to  contract  epi- 
demic cholera  on  either  ocean  or  river  steamers;  for,  in  spite  of  the  asser- 
tions of  Pettenkofer,  ships  do  become  cliolera-infccted,  and  do  transmit  the 
disease  to  individuals  who  come  upon  their  decks  in  absolute  health. 
Apart  from  the  fatigues  of  long  marches,  troops  are  no  longer  liable  to  be 
temporarily  encamped  on  old  and  infected  grounds  where  they  may  receive 
the  cholera  poison.  No  longer  are  they  the  agents  in  the  diffusion  of  the 
disease  to  isolated  communities  or  to  other  bodies  of  moving  men. 

The  experiences  in  the  United  States  of  all  cholera  epidemics  from  1832 
to  1873  can  scarcely  be  reduplicated.  The  disease  in  its  every  type  re- 
mains the  same,  but  the  liability  of  contact  on  the  part  of  troops  has  been 
materially  lessened.  But  while  the  probability  of  troops  coming  in  con- 
tact with  and  becoming  infected  by  cholera  has  been  greatly  lessened,  still 
by  the  increased  facility  and  rapidity  of  railroad  travel  the  possibility  of  a 
wide-spread  diffusion  of  the  disease  has  been  considerably  enhanced.  In 
the  American  Practitioner  for  August  and  September,  1874,  I  endeavored 
to  call  attention  to  the  marked  agency  of  common  carriers  as  porters  of 
disease.  In  the  "  History  of  the  Cholera  Epidemic  of  1873  in  the  United 
States,"  published  in  1875,  I  again  endeavored  to  present  the  subject  for 
consideration;  and  I  would  once  more  press  the  same  view.  On  cholera- 
infected  steamers,  where  either  passengers  or  crew  can  gain  access  to  the 
mass  of  merchandise  transported,  the  diffusion  of  clwlera  may  be  wide- 
spread and  mysterious.  Who  can  say  what  results  may  not  follow  the 
voiding  of  one  cholera  dejection  on  a  box  of  dress-fabrics  (of  any  kind), 
or  on  a  bale  of  cotton;  and  yet  the  opening  of  one  or  the  other  may  occa- 
sion a  serious  local  epidemic  of  the  disease,  which  might  be  advanced  as 
another  instance  in  proof  of  the  ground-water  theory,  or  some  equally  ab- 
surd view. 

If  the  excreta  of  individuals  suffering  from  cholera  are  the  active  agents 
in  the  reproduction  of  that  disease,  has  not  the  common  carrier  who 
transports  an  individual  suffering  in  any  stage  of  that  disease  over  two  or 
three  hundred  or  more  miles  of  territory  in  a  day  a  very  active  agency  in 
''sowing  the  seeds"  of  cholera?  The  limited  express  which  leaves  New 
York  each  morning  traverses  the  long  distance  to  Chicago  in  but  a  little 
over  twenty-four  hours.  Suppose  a  single  individual  on  that  train  has 
choleraic  diarrhoea:  who  can  answer  when,  and  where,  and  how  often  his 
dejecta  are  sown  broadcast  ?  It  may  be  in  an  uninhabitable  locality,  but  it 


CHOLERA  HYGIENE  AS  APPLIED  TO  MILITARY  LIFE.        3^5 

is  jnst  as  likely  to  be  on  entering  some  town  or  village,  or  they  may  be 
thrown  upon  the  door-sill  of  some  outlying  farm-house. 

Below  the  saloon  end  of  each  car  there  should  be  a  tank  for  the  recep- 
tion of  all  excremental  matter,  containing  an  active  disinfectant,  and  at 
fixed  points  along  all  railways  these  tanks  should  be  moved  and  emptied 
by  trained  employees.  Could  this  be  accomplished,  we  would  hear  less  of 
mysterious  outbreaks  of  cholera,  which  can  only  be  accounted  for  on 
"  endemic  '*  theories. 

While  long  marches  are  no  longer  a  necessity  in  the  movements  of 
troops,  it  by  no  means  follows  that  the  United  States  soldier  is  no  longer 
liable  to  duty  in  the  field.  In  the  exchange  of  station  from  one  depart- 
ment to  another,  the  march  is  still  made.  This  is  especially  true  as  to  the 
mounted  regiments.  In  many  instances  military  posts  are  located  from 
one  to  two  hundred  miles  from  the  nearest  railway.  On  the  frontier  the 
depredations  of  hostile  Indians  occasionally  demand  extended  and  pro- 
longed field  operations.  For  the  instruction  of  troops  in  field  duties,  sum- 
mer campaigns  are  frequently  made. 

Should  cases  of  cholera  occur  among  troops  in  camp  or  on  the  march, 
the  same  line  of  management  as  has  already  been  indicated  should  be  ob- 
served. The  hospital  camp  should  always  be  at  a  convenient  distance  to 
the  leeward  of  the  main  camp.  Deep  narrow  pits  should  be  dug  to  re- 
ceive the  excreta,  and  it  should  always  be  a  matter  of  great  care  that  all 
privies,  /'or  tlie  well  and  for  the  siek\  should  be  so  placed  as  to  prevent  the 
possibility  of  infection  of  any  wells  or  springs  in  their  vicinity.  No  matter 
what  may  have  to  be  abandoned,  a  sufficient  number  of  ambulances  or 
wagons  should  be  provided  for  the  transportation  of  the  sick.  If  possible, 
the  daily  march  should  be  made.  The  morale  of  the  command  is  pre- 
served by  action;  a  daily  change  of  camp-ground  is  a  daily  removal  from 
the  cholera  germ  that  has  escaped  from  the  human  body,  for  this  (al- 
though they  may  be  told  that  the  germs  have  been  destroyed  by  disinfect- 
ants) is  greatly  dreaded  by  the  soldiers.  It  is  well  to  avoid  in  a  march 
the  ordinary  line  of  travel.  The  simplest  case  of  diarrhoea  should  be 
taken  from  the  ranks  and  placed  in  the  hospital  wagon,  and  every  such 
case  should  be  placed  under  treatment  so  soon  as  it  is  discovered. 

Before  leaving  a  camp-ground  it  should  be  a  matter  of  solicitude  that 
nothing  is  left  which  by  any  possibility  may  convey  the  disease  to  those 
who  may  follow.  After  the  line  of  march  is  taken  up  and  all  have  left 
the  site,  a  police  party  should  inspect  every  portion  of  the  ground.  They 
should  see  that  every  pit  is  securely  disinfected  and  solidly  covered;  and 
debris,  no  matter  of  what  character,  should  be  either  burned  or  buried. 
Before  each  day's  use  the  ambulances  and  wagons  should  be  thoroughly 
washed  with  disinfecting  fluid.  At  the  rear  of  the  column  a  sanitary 
detail  should  march,  who  should  inspect  the  dejecta  of  any  man  who  may 
have  occasion  to  fall  out  by  the  way.  Even  a  solid,  healthy-looking  de- 
jection should  be  treated  with  suspicion,  and  should  receive  the  disinfect- 
ant before  being  buried. 

Men  should  under  no  circumstances  be  permitted  to  leave  the  ranks 
for  drinking-water.  A  supply  which  has  been  boiled  and  strained  should 
be  carried  on  the  march;  and'  it  is  advisable  that  the  men  carry  cold  tea 
in  their  canteens. 

There  remains  but  a  consideration  of  the  disposition  which  should  be 
made  of  cholera-infected  fabrics.  That  all  inanimate  objects,  especially 
woolen  and  cotton  fabrics,  can  and  do  act  as  storehouses  of  the  specific 


3g(3  ASIATIC  CHOLERA. 

seeds  of  cholera  has  been  so  Often  proven  tliat  it  is  not  now  necessary  to 
reiterate  the  fact. 

Among  soldiers  the  articles  npon  which  such  a  fixation  can  occur  are 
all  articles  of  clothing,  blankets,  l)ed  furniture  and  tents.  After  use  about 
a  patient  attacked  with  the  disease,  it  is  in  my  opinion  unsafe  to  continue 
any  articles  in  service,,  even  should  a  careful  disinfection  have  been  at- 
tempted. Each  and  every  article  which  has  come  in  contact  with  cholera 
sick  should  be  thoroughly  treated  with  disinfectants,  dried  and  finally 
destroyed  by  fire;  on  the  subsidence  of  the  epidemic.  This  advice  is  based 
upon  experience  in  past  epidemics.  It  is  a  radical  opinion ;  but  when 
epidemic  cholera  comes  to  be  treated  by  radical  measures  alone,  when  theo- 
ries impracticable  in  all  their  proportions,  and  which  are  persisted  in 
simplv  for  personal  aggrandizement — give  place  to  radical  and  practicable 
proced^^res — Epidemic  Cholera  will  be  unknown  npon  the  American  Con- 
tinent. 

How  shall  a  case  of  cholera  be  managed  when  it  develops  upon  a  rail- 
road train  in  motion  ?  To  allow  the  dejecta  of  such  a  patient  to  be  emptied 
upon  the  road-bed  is  criminally  to  assist  in  the  spread  of  the  disease.  No 
other  vessels  being  at  hand,  the  coal  box,  one  of  which  lined  with  zinc  is 
in  every  car,  should  be  brought  into  requisition,  and  each  discharge  into 
it  should  be  covered  with  ashes  brought  from  the  engine.  At  the  first 
station  reached,  the  patient  should  be  removed  from  the  train  and  placed 
in  reliable  hands.  A  supply  of  disinfecting  agents  should  be  obtained;  the 
contents  of  the  vessel  employed  to  receive  the  dejecta  should  be  actively 
treated  with  the  germicide  and  buried;  the  car  which  had  been  occupied 
by  cholera  should  be  washed  with  the  disinfecting  agent,  and  during  the 
remainder  of  the  journey  be  fully  ventilated.  Every  Avindow  should  be 
open  so  that  the  air  contained  by  every  portion  may  be  constantly  changed. 
It  is  imperative  that  the  excreta  of  a  cholera  patient  leave  the  car  with, 
not  before,  the  patient. 


PART  SEVENTH. 


THE  TREATMENT  OF  CHOLERA. 


BY 

EDMUND  C.  WENDT,  M.D., 

OF  NEW  YORK. 


FALSE  NOTIONS  REGARDING  CHOLERA.  3^9 


CHAPTER   XLIIL 

GENERAL  THERAPY  AND  THE  TREATMENT  OF  THE  DIFFERENT 
STAGES  OF  AN  ATTACK. 

General  Remarks. — It  is  safe  to  assert  that  in  no  other  disease  have 
the  remedies  employed  and  the  general  methods  of  treatment  been  more 
numerous,  than  in  the  attempted  cure  of  Asiatic  cholera.  Some  writers 
have  manifested  surprise  and  dismay  at  this  bewildering  state  of  affairs. 
It  is  only  too  true  that  an  examination  of  the  results  achieved  by  the  most 
intelligent  therapeutic  efforts  is  far  from  encouraging.  Yet  there  is  no 
just  ground  for  the  expression  of  surprise  that  countless  remedies  should 
have  been  tried  and  recommended  in  the  treatment  of  the  disease.  On 
the  contrary  nothing  would  seem  to  be  more  natural.  For,  on  reflection, 
the  multiplicity  of  counsel  regarding  the  therapy  of  cholera  must  appear 
to  be  only  the  inevitable  consequence  of  advising  action  in  accordance 
with  the  extremely  divergent  views  held  concerning  the  nature  of  the 
disease.  .  Again,  the  lack  of  success  that  has  necessarily  attended  all  efforts 
to  save  the  doomed,  or  cure  the  incurable,  is  in  a  measure  responsible  for 
the  suggestion  of  the  most  extravagant  and  ridiculous  means  of  attaining 
this  end.  Indeed  the  whole  history  of  medicine  abundantly  exemplifies 
the  rule  that,  the  further  removed  from  human  ken  and  power  a  disease 
may  be,  the  greater  will  also  be  the  number  and  variety  of  agents  recom- 
mended for  its  positive  cure.  If  the  subject  were  a  less  serious  one,  it 
woidd  be  quite  amusing  to  scan  the  absurd  notions  that  have  arisen,  and 
still  arise,  whenever  epidemic  cholera  makes  its  appearance  in  our  most  civil- 
ized countries.  This  applies  not  only  to  the  pardonable  popular  fallacies  con- 
cerning it,  but  to  theories  and  recommendations  emanating  from  the 
ranks  of  the  medical  profession  itself.  Stille  alludes  to  a  numloer  of  such 
views  in  the  following  way: 

Cholera  has  never  prevailed  in  any  country  without  giving  rise  to  extraordinary 
theoretical  and  practical  divagations.  One  physician  in  the  earliest  Aniei'ican 
epidemic  gravely  proposed,  as  the  best  mode  of  checking  the  diarrhcea,  to  plug- 
the  anus  witli  a  soft  velvet  cork.  Another,  in  England,  suggested  that  the  "  blood 
may  be  kept  circulating  by  putting-  the  patient  on  his  back  on  a  board  and  keep- 
ing up  a  rocking,  see-saw,  to-and-fro  movement  from  eighty  to  one  hundred  times 
a  minute."  Another  had  the  revelation  that  the  disease  is  essentially  a  "  paralysis 
of  the  sympathetic  nerve  and  want  of  performance  of  the  organic  functions,  with 
deficient  vitality  of  the  mucous  membranes,"  and  that  its  proper  remedies  are 
"bleeding,  turpentine,  and  cool  drinks,  without  heat  and  stinnilants;"  and  to 
this  remarkable  doctrine  a  well-known  physician  gives  his  adhesion,  thus:  "The 
cause,  I  firmly  believe,  is  a  union  of  the  poison  witii  the  sympathetic."  '  "Were 
not  the  evidence  so  palpable,  it  would  hardly  be  believed  that  such  irrational  ideas 
should  have  been  published  concerning  a  disease  which  had  then  been  under  ob- 
servation by  the  whole  medical  profession  in  Europe  and  America  for  more  than, 
thirty  years,  and  in  Asia  for  a  much  longer  period. 

'Times  and  Gazette,  Aug.,  1866,  p.  209;  ibid.,  Nov.,  1866,  p.  555. 
24 


370  ASIATIC  CHOLERA. 

To  this  sliort  list  a  few  other  views,  more  recently  propounded,  may- 
be added  in  further  illustration  of  the  subject.  Thus  Dr.  Grotius,  a 
former  naval  surgeon,  who  was  decorated  for  his  services  during  the  epi- 
demic of  1865-G6,  and  who  appears  to  have  an  irrepressibly  facetious  vein, 
thinks  that  cholera  is  a  disease  characterized  by  a  little  colic  and  diarrhoea, 
and  a  vast  amount  of  fear. ' 

Hence  this  learned  gentleman,  in  all  seriousness,  advises  patients  in  the 
algid  stage  of  cholera  simply  to  react  from  their  fear  and  colic  and  thus  to 
turn  the  crocodile  tears  of  the  expectant  heirs  into  genuine  grief.  For  he 
is  convinced  that,  as  a  rule,  cholera  is  a  bad  joke  invented  for  the  terror- 
ization  of  mankind.  It  seems  incredible  that  such  extravagant  nonsense 
should  be  published  by  physicians  who  have  enjoyed  the  privileges  of  a 
liberal  education.  Yet  examples  of  this  kind  might  be  multiplied  almost 
ad  libitum. 

Take  the  following  statements,  made  by  an  Italian,  who  proves,  to  his 
own  satisfaction  at  least,  that  cholera 

is  nothing  more  than  a  consequence  of  the  displacement  of  the  worms  of  which 
we  are  made  up.  A  sudden  fear,  an  indigestion,  or  any  other  disorder  which  shakes 
but  does  not  kill  the  delicate  mass  of  worms,  will  arouse  them,  and  they,  leaving 
their  noi'mal  place,  will  assail  and  suffocate  the  patient,  as  frequently  happens  in 
nursing  children.  The  rice  pap  discharges  are  nothing  else  but  a  mass  of  smaller 
worms  with  their  excreta,  triturated  by  the  current  of  the  larger  worms  which 
assail  the  belly,  stomach  and  tlu'oat.  The  greater  or  less  intensity  of  the  assault 
is  proportionate  to  the  greater  or  less  intensity  of  tlie  disease,  and  hence  the 
cholerine,  the  cholera,  and  the  cholerone.'^ 

In  accordance  with  this  brilliant  etiological  conception  of  the  disease, 
the  inventor  thereof  proposes  the  use  of  "  remedies  to  pacify  and  replace 
the  worms,  and  to  kill  those  which  are  enraged  when  they  threaten  our 
lives  with  deadly  assaults,  viz. :  For  cholera  and  cholerine,  strong  coffee, 
olive  oil,  ritm,  bitter  decoctions,  etc.  For  the  cliolerone  the  same  . 
according  to  the  strength  of  the  patient. " 

A  recent  French  writer,  M.  Alliot,'  defines  cholera  as  an  obliteration 
or  chemical  modification  of  the  metachemical  essence  (nervous  or  electric 
fluid)  which  constitutes  the  vital  principle  of  man.  Such  being  the  case 
the  proper  remedy  is  pilocarpine.  This  may  not  appear  to  be  quite  logical, 
but  it  is  certainly  very  amusing. 

From  this  digression  we  turn  now  to  the  serious  consideration  of  the 
best  means  at  our  command  for  a  rational  treatment  of  patients  attacked 
with  the  disease.  And  here,  at  the  very  outset,  Ave  would  ask  the  reader 
to  remember  that  the  power  of  drugs  to  influence  an  aggravated  attack 
of  Asiatic  cholera  is  often  nil,  and  at  best  exceedingly  limited.  But  is 
not  the  same  thing  observed  in  other  truly  malignant  diseases,  as  well  as 
in  accidents  that  have  disabled  some  vital  organ?  AYe  must  not  ascribe,  as 
has  been  done,  the  occasional  marvelous  recovery  from  cholera  to  any  cura- 
tive effects  of  the  particular  medicinal  agents  employed  in  such  exceptional 
cases.  Enlightened  physicians,  all  the  world  over,  freely  admit  that  certain 
grave  types  of  fever,  some  attacks  of  malignant  scarlatina  or  diphtheria,  may 
so  quickly  and  completely  overwhelm  the  system,  as  Avith  a  deadly  venom, 
that  the  agency  of  drugs,  even  Avhen  combined  with  the  most  judicious  gen- 

'  La  Verite  svir  le  Cholera.  Precautions  a  prendre  pour  eviter  slirement  le  fleau, 
et  moj'ens  radicaux  pour  le  guerir.    Biaissels,  1884. 

•^  Quoted  from  an  Italian  letter  published  in  the  Chicago  Medical  Journal  and 
Examiner,  Januarj',  1885. 

2  Traitement  du  Cholera  par  la  Pilocarpine.     Paris,  1884. 


FUTILITY  OF  SPECIFIC   TREATMENT.  371 

eral  management,  is  utterly  impotent  to  effect  a  cure.  And  let  us  not  for- 
get that  there  is  no  disease  which,  in  its  malignant  manifestations,  acts  with 
greater  energy  and  speedier  virulence  than  Asiatic  cholera.  It  cannot, 
therefore,  be  justly  construed  as  a  reproach  to  the  science  and  art  of 
medicine  that  we  have  no  power  in  such  cases  of  stemming  the  tide  that 
hurries  the  patient  to  an  inevitable  doom. 

Having  thus  frankly  acknowledged  our  helplessness  with  regard  to  the 
worst  types  of  the  disease,  we  must  on  the  other  hand  emphatically 
assert  our  power  to  deal  successfully  with  cholera  in  its  earliest  and  mildest 
manifestations.  It  is  true  that  even  here  our  power  may  be  limited,  but 
to  dispute  it  completely  would  be  as  much  of  an  error,  as  to  claim  it  with 
regard  to  the  graver  attacks  of  well-marked  cholera. 

At  this  point  the  question  naturally  arises,  if  cholera  is  a  specific  dis- 
ease, dependent  upon  the  invasion  of  intestinal  parasites,  why  is  it  not 
possible  to  abort  an  attack  by  the  early  employment  of  parasiticides. 
There  are  several  answers  to  this  query.  In  the  first  place,  assuming  the 
truth  of  the  micro-parasitic  doctrine  of  cholera,  it  has  been  shown  by  Koch 
and  others  that  the  destruction  of  the  specific  bacilli  within  the  intestinal 
canal  is,  in  the  present  state  of  our  knowledge,  impracticable.  For  it 
would  in  most  cases  necessitate  the  employment  of  drugs  that  would  prove 
as  surely  fatal  to  the  host  as  to  his  parasites. '  Again,  as  for  example  in 
trichinosis,  by  the  time  the  symptoms  of  an  invasion  make  diagnosis  pos- 
sible, the  fatal  harm  may  be  already  accomplished,  and  the  most  potent 
parasiticides  would  then  arrive  too  late.  AYithout  wishing  to  discourage 
too  much  the  continued  search  for  a  specific  against  cholera,  it  may  be 
well  to  remember  that,  should  one  be  discovered,  it  would  fail  to  check  an 
attack  of  the  disease  except  when  employed  sufliciently  early  to  prevent 
the  very  symptoms  upon  which,  in  most  cases,  we  base  our  diagnosis  of 
this  malady. 

Semmola '"  has  recently  published  some  suggestions  regarding  the  man- 
agement of  cholera  that  have  a  direct  bearing  on  the  question  under  dis- 
cussion. He  boldly  states  his  conviction  that  the  parasitic  doctrine  can 
never  be  taken  as  the  point  of  departure  for  rational  treatment.  For,  as 
intimated  above,  apart  from  the  difficulty  of  using  enough  of  a  sufficiently 
strong  parasiticide  to  kill  all  the  microbes,  their  poisonous  action 
(ptomaines)  is  already  accomplished  by  the  time  we  have  positive  symp- 
tomatic indication  of  their  presence  in  the  human  body.  Indeed  Semmola 
goes  so  far  as  to  state  that  the  diarrhoea  of  cholera,  instead  of  being  due 
to  the  local  and  primary  visitation  of  the  microbes,  may  be  regarded  as 
the  first  result  of  poisoning  of  the  nerve-centers  and  abdominal  sympa- 
thetic, which  have  an  undeniable  influence  over  intestinal  nutrition  and 
circulation.  He  thinks  it  probable,  also,  that  in  cholera  there  occurs  in- 
testinal absorption  of  the  poison  generated  by  the  microbes,  which,  enter- 

'  It  is  of  coui'se  possible  tliat  future  research  may  provide  us  with  some  agent 
that,  while  a  reliable  parasiticide,  may  be  devoid  of  toxic  properties  so  far  as  the 
human  being  is  concerned. 

The  dilute  mineral  acids  are  remedies  which  have  a  large  experience  in  their 
favor,  and  rest  also  on  an  apparentlj'  sound  theoretical  basis.  Weak  chlorine 
water  may  also  be  thought  of;  and  it  is,  of  course,  possible  to  give  corrosive  sub- 
limate so  dilute  as  to  be  harmless.  But  even  if  these  remedies  kill  germs  we  must 
remember  that  germicides  are  not  antidotes  to  ptomaines  and  like  poisons.  See 
also  Dr.  Sternberg's  article  on  Internal  Disinfection,  in  the  preceding  part. 

^  Nouvelles  Reclierches  thera{)euti(|ues  sur  le  cholera  asiatique,  in  Bulletin 
general  de  therapeutique,  December  15,  1884,  p.  48"2. 


372  ASIATIC   CHOLERA. 

ing  the  circulation,  acts  successively  iipon  the  various  nerve  centers, 
presiding  over  the  functions  that  are  observed  to  become  progressively 
disturbed. 

For  him  it  is  certain  that  all  anti-parasitic  remedies  hitherto  recom- 
mended, amount  to  nothing  more  than  "scientific  charlatanism."  The 
"quinine"  of  cholera,  if  the  term  may  be  used,  has  not  yet  been  dis- 
covered, and  Semmola  thinks  that  it  is  not  likely  to  Ije  found  by  labora- 
tory methods.  Still,  he  believes  it  is  a  great  mistake  to  confound  paludal 
with  choleraic  infection.  And  certainly  the  exhibition  of  anti-periodics 
in  cholera  is  useless,  and  the  reported  cures  are  readily  explained  as  errors 
of  observation. 

In  view  of  the  difficulties  briefly  alluded  to  in  the  above,  it  is  doubtless 
a  legitimate  question  whether  treatment  by  drugs  is  indicated  at  all  in  the 
management  of  cholera-patients?  This  question,  as  already  intimated, 
must  be  answered  in  the  affirmative.  And  this,  too,  in  spite  of  the  ex- 
tremely pessimistic  views  entertained  by  some  writers  of  extended  experi- 
ence. 

As  long  ago  as  1847  Parkes'  wrote  as  follows:  "  Xo  medicine  has  yet 
been  found  which  can  counteract  the  changes  in  the  fibrine,  and  nul- 
lify the  first  effect  of  the  choleraic  virus  in  the  blood.  The  antidote  to 
this  tremendous  virus  has  not  yet  been  discovered,  and  the  resources  of 
modern  European  science  have  opposed  its  destructive  action  with  as  little 
effect  as  the  untutored  efforts  of  the  most  barbarous  nation  to  Avhom  its 
ravages  are  known.  The  efforts  of  European  science  have  indeed,  it  appears 
to  me,  in  many  cases  proved  hurtful.  The  attempt  to  cut  short  the 
disease,  and  to  rouse  the  s^^stem  from  a  state  erroneously  compared  to  de- 
bility and  to  exhaustion,  has  certainly  often  accelerated  the  progress  of 
cholera.  It  is  a  most  important  practical  point  that  cholera  runs  a  certain 
course;  when  the  algid  symptoms  have  once  shown  themselves,  a  case 
cannot  be  cut  short;  even  in  the  mildest  forms,  Avarmth  does  not  return 
altogether  for  a  long  time,  but  Avhen  the  disease  has  reached  its  acme  the 
patient  is  invariably  seen  to  remain  for  some  hours  in  a  peculiar  state, 
during  which  time  nature  seems  to  be  gradually  repairing  the  injury  Avhich 
has  been  done.  Therefore  when  a  person  is  cold  and  almost  piilseless, 
with  a  heart  embarrassed  and  a  respiration  nearh^  arrested,  the  attempt 
violently  to  rouse  him  from  this  state  b}'  strong  stimulants,  by  warmth  to 
the  surface,  by  continued  frictions,  or  by  measures  of  a  like  kind,  seems 
to  me  to  be  founded  altogether  on  a  mistipprehension." 

There  is  no  gainsaying  the  truth  of  much  that  is  contained  in  the 
foregoing  quotation.  As  illustrative  of  opinions  also  partaking  of  a  de- 
cidedly hopeless  character,  we  may  cite  some  statements  quite  recently 
made  by  Dr.  D.  B.  Simmons,'^  who  has  had  a  very  large  experience  in  the 
treatment  of  cholera  in  many  of  the  countries  of  Eastern  Asia,  from  Japan 
to  India.  He  points  out  that  the  statistics  of  the  late  epidemic  in  Europe 
show  a  mortality  of  50  per  cent.  His  own  statistics  of  the  mortality  in 
Asia  give  the  same  average  rate  of  50  per  cent.  In  the  former  case  the 
majority  of  the  patients  received  treatment  directed  by  men  well  informed 
concerning  all  the  remedial  agents  known  to  modern  scientific  medicine. 
In  the  latter  class,  however,  not  one  patient  in  a  thousand  Avas  seen  by 
physicians  of  the  Western  school.     In  fact  great  numbers  of  them  were  not 

'  Researches  into  the  Pathology'  and  Treatment  of  the  Asiatic  or  Algide  Cholera. 
By  E.  A.  Parkes,  M.D.,  London:  1847,  p.  203. 
2  The  Medical  Record,  March  7,  1885. 


TREATMENT  OF  PREMONITORY  DLIRRHCEA.  373 

visited  by  the  doctors  of  any  school,  preferring  to  pnt  their  trust  in  charms 
and  prayers  to  their  various  divinities,  having  from  long  exiserience  had 
quite  as  much  reason  for  belief  in  the  curative  powers  of  one  as  of  the 
other.    He  thinks  it  is  not  necessary  to  add  the  moral  to  the  above. 

So  long  ago  as  1865  Velpeau  '  wrote  as  follows:  •''  It  is  not  impossible 
that  a  notable  number  of  cholera  patients  recover  without  remedies  or 
specifics,  and  in  spite  of  them;  and  the  proof  is  that  in  all  epidemics — in 
the  violent  one  of  1832,  as  well  as  those  of  1849  and  1854 — more  than  one- 
half  of  the  cholera  patients  have  recovered — have  recovered  by  methods  of 
treatment  most  opposed  and  various."' 

Against  such  views,  the  unqualified  acceptance  of  which  would  con- 
traindicate  all  medical  interference,  we  maintain  that  accumulated  clinical 
experience  of  an  unimpeachable  kind  makes  it  appear  extremely  probable 
that  the  early  stages  of  specific  cholera  are  amenable  to  treatment.  Dr. 
Leale*  goes  so  far  as  to  state  that  "a  very  large  proportion  of  even  the 
severest  cases  of  the  disease  may  end  in  recovery  if  the  proper  medicinal 
treatment  is  early  resorted  to,  and  our  profession  can  point  with  jiride  to 
its  success  in  promoting  a  convalescence,  or,  at  the  early  stage,  in  prevent- 
ing the  violence  of  the  disease  from  killing  the  sufferer." 

So  that,  while  strongly  deprecating  blind  interference,  we  nevertheless 
hold  that  the  physician  is  not  justified  in  merely  folding  his  hands  in  re- 
signed inaction,  in  the  face  of  this  unpromising  disease.  Therefore  when 
called  upon  to  assume  the  chai'ge  of  a  case,  even  in  the  advanced  stage  of 
the  attack,  his  counsel  must  not  be  withheld  on  the  ground  that  nothing 
will  avail.  Death  alone  can  command  a  cessation  of  honest  effort  to  rescue 
the  poor  sufferer  from  his  impending  fate.  Though  fully  convinced  that 
his  best  endeavors  are  likely  to  prove  futile,  duty  clearly  demands  that 
the  physician  do  all  in  his  power  to  assist  the  victim  of  cholera,  in  the 
same  way  that  he  would  unhesitatingly  assist  a  sufferer  from  any  chronic 
form  of  incurable  disease.  If  he  cannot  stay  the  morbid  process,  he  has 
at  least  some  power  to  relieve  suffering,  assuage  anxiet}',  and  stimulate 
failing  hope. 

He  should  be  careful  not  to  make  the  mistake  of  the  good  Kentucky 
doctor,  Avho  when  grievously  importuned  to  prescribe  for  a  cholera 
patient  in  apparently  hopeless  collapse,  added  to  his  prescription  "  to  be 
given  every  hour  until  he  dies,"  and  found  his  patient  almost  convalescent 
at  his  next  visit.     (Peters). 

The  Treatment  of  Premonitory  Diarrhoea  and  Cholerine. — 
Under  this  and  the  following  heading  we  propose  to  sketch  such  a  general 
plan  of  treatment  as  we  conceive  to  be  in  accordance  with  our  present 
knowledge  of  the  disease,  but  which  is  above  all  things  supported  by 
rational  clinical  empiricism.  This  may  be  profitably  supplemented  by 
some  account  of  particular  methods  or  remedies  that  have  received  the 
sanction  of  authority,  or  whose  claims  to  recognition  have  been  warmly 
urged,  more  particularly  during  the  recent  European  outbreak. 

In  the  prevalence  of  an  epidemic,  the  safest  rule  in  practice  is  to  treat 
every  case  of  diarrhoea,  no  matter  how  slight,  with  the  iitmost  care,  and 
on  the  principle  that  it  may  be  premonitory  of  a  grave  attack  of  Asiatic 
cholera.  It  goes  without  saying  that  the  physician  must  studiously  avoid 
causing  unnecessary  apprehension,  or  spreading  alarm  among  his  clientele. 

'  L'Abeille  Medicale,  November  13,  1865. 

2  The  New  York  Medical  Journal,  February  21,  1885. 


374  ASIATIC  CHOLERA. 

Yet  by  exercising  the  necessary  amount  of  tact,  the  families  composing 
his  practice  may  be  informed  of  the  urgent  necessity  of  attending  imme- 
diately to  the  most  insignificant  intestinal  derangements,  that  ordinarily 
might  be  disregarded. 

If  slight  diarrhoea  occurs  and  is  clearly  traceable  to  errors  or  excess  in 
eating,  and  if  there  is  reason  to  believe  that  undigested  food  is  still  irri- 
tating the  bowels,  a  mild  laxative,  such  as  castor-oil  or  the  usual  salts  Avith 
a  little  opium,  may  be  safely  given.  No  possible  harm  can  result  from  a 
single  dose  of  an  unirritating  laxative.  And  even  should  the  sequel  show 
that  the  case  was  one  of  choleraic  diarrhoea,  the  physician  may  rest  assured 
that  the  attack  was  not  aggravated  by  his  remedy.  No  sooner  has  the 
laxative  produced  its  effect  of  removing  the  offending  matters,  than  amj 
persistence  of  diarrhoea  should  be  followed  by  the  prompt  administration 
of  opiates  in  small  or  moderate  doses,  repeated  at  short  intervals.  If 
there  is  no  distinct  evidence  pointing  to  the  presence  of  irritating  bowel 
contents,  the  preliminary  laxative  is  contraindicated,  and  ti-eatment  by 
opium  may  be  at  once  begun.  If  the  distress  is  gastric  rather  than  intes- 
tinal, an  emetic  dose  of  ipecac  is  a  preliminary  measure  of  undeniable  ad- 
vantage. In  fact  Briquet,  Laugier  and  Ollive,  and  quite  recently  Fabre, 
commonly  employ  this  drug,  and  warmly  recommend  it  not  only  in  the 
premonitory  stage  of  an  attack,  but  also  after  the  disease  has  actually 
begun. 

Fabre  '  uses  it  even  when  grave  phenomena  already  exist,  provided  the 
tongue  is  coated  sufficiently  to  indicate  gastric  derangement.  He  remarks 
that  it  is  surprising  to  witness  the  calm  that  follows  the  vomiting,  to  ob- 
serve the  pulse  rise,  a  moisture  bedewing  the  limbs,  the  cramps  cease,  the 
countenance  lose  its  pinched  appearance,  and  the  general  condition  of  the 
patient  improve.  Saline  emetics  are,  hoAvever,  universally  condemmed, 
and  without  sharing  the  sanguine  vicAVS  of  the  French  writer  just  cited, 
it  may  yet  be  worthy  of  remembrance  that  when  an  emetic  is  advisable 
our  choice  should  fall  upon  ipecacuanha  in  preference  to  other  similarly 
acting  drugs. 

But  to  resume:  A  few  drops  of  some  mineral  acid  (nitric,  or  hydro- 
chloric, but  preferably  sulphuric)  largely  diluted  with  water  and  taken 
frequently,  may  be  added  to  the  treatment  by  opium;  not  merely  in  the 
hope  of  destroying,  as  Macnamara  and  many  others  believe,  ''the  specific 
cholera  process  going  on  in  the  intestinal  canal,  "^  but  because  it  is  grateful 
and  slightly  astringent,  and  also  for  the  purely  empirical  reason  that 
patients  have  seemed  to  be  benefited  thereby. 

]\Iore  impoftant,  however,  than  the  use  of  opiates  and  acids,  even 
at  this  early  stage,  Ave  hold  to  be  the  general  regimen  of  the  patient.  He 
should  be  instructed  to  cease  all  Avork  at  once,  if  possible  to  eat  and  drink 
nothing  for  several  hours,  and  to  lie  doAvn  either  in  bed  or  on  a  sofa,  pref- 
erably betAveen  blankets,  Avith  a  flannel  bandage  applied  over  the  abdomen. 
A  Avell-aired  room,  in  Avhich  an  equable  temperature  is  maintained,  should 
be  provided  for  the  patient's  occupancy.  Bland  fluids,  such  as  egg-water 
or  mucilaginous  decoctions,  also  soaked  toast,  gruels,  farina,  rice,  may  be 
alloAved,  if  after  about  eight  hours  of  rest  and  abstinence  there  is  no  return 
of  the  diarrluea.  Beef-tea  and  all  concentrated  meat  broths  should  be 
interdicted,  even  those  prepared  Avitli  muriatic  acid.  For  several  days 
folloAving  a  AA'arning  of  this  kind,  the  patient  should  be  directed  to  strictly 

'  Traitement  du  Cholera.  Legons  faites  par  le  Professeur  A.  Fabre.  Marseilles, 

1884. 


PREMONITORY  DIARRHCEA.  375 

regulate  his  diet,  and  carefully  avoid  all  fatigue  and  nervous  perturbation. 
Should  the  diarrhoea  return  after  a  number  of  days,  he  must  once  more  fast 
and  rest  as  before,  and  agam  only  gradually  venture  on  returning  to  his 
normal  diet. 

This  simple  line  of  treatment  is  the  most  i-ational  as  well  as  successful 
mode  of  dealing  with  the  mild  diarrhoeal  manifestations  that  are  so  fre- 
quently seen  during  the  prevalence  of  an  epidemic.  It  is  true  that  it  will 
not  always  be  possible  to  induce,  for  example  an  active  business  man  to 
carry  out  measures  that  entail  a  certain  amount  of  discomfort,  and  ne- 
cessitate absence  from  his  "  office  "  for  hours  or  even  days.  Yet  obedience 
to  the  above  advice  should  be  strenuously  urged,  and  in  a  large  proportion 
of  cases  will  meet  with  little  or  no  opposition. 

Regarding  the  preparations  of  opium,  it  is  best  to  use  the  tinctures  e.g. 
laudanum  or  paregoric  in  preference  to  powders,  pills,  or  any  of  the 
alkaloids  of  the  drug.  In  some  cases  it  may  be  advisable  to  combine  an 
astringent  with  the  opium,  but  generally  laudanum  alone,  or  in  strong 
peppermint  water,  is  preferable  to  such  combinations.  Kino,  catechu,  and 
tannin  are  among  the  most  serviceable  drugs  when  astringents  are  required. 

Macnamara  was  in  the  habit  of  distributing  "  cholera  pills,"  among 
the  well  during  the  prevalence  of  an  epidemic.  Each  pill  contained  a 
grain  of  opium  and  two  grains  of  acetate  of  lead,  the  directions  being 
that  one  be  taken  every  hour  until  purging  stops.  It  is  certainly  advisable 
in  times  of  cholera  to  have  bureaus,  offices,  factories,  schools,  and  indeed 
all  places  where  people  congregate,  supplied  Avith  some  simple  opiate,  so 
that  the  first  manifestations  of  diarrhoea  may  be  promptly  met  by  appro- 
priate medication.  Of  course  the  medicine  should  be  placed  in  intelligent 
hands,  and  each  bottle  or  pill-box,  must  be  labeled  with  explicit  directions 
for  use. 

For  children  and  very  delicate  persons  paregoric  is  preferable,  as  all 
the  spices  and  aromatics  are  germicides.  Laudanum,  if  distasteful,  may 
be  given  in  peppermint  or  some  other  aromatic  water,  of  which  aq.  menth. 
virid,  aq.  carui,  anisi,  allspice  or  cloves  are  not  to  be  despised.  In  other 
cases  a  solution  of  morphine  in  acidulated  water,  or  in  aromatic  water,  may 
be  more  useful  and  acceptable. 

Dr.  Fergus, '  of  Glasgow,  had  a  number  of  rules  drawn  up  and  hung 
in  prominent  places  of  that  city,  during  the  prevalence  of  cholera  there. 
They  contain  practical  suggestions,  as  applicable  to-day  as  they  were  then, 
and  are  therefore  here  reproduced,  with  certain  changes  that  have  sug- 
gested themselves  to  the  editor. 

1.  Do  not  be  afraid  of  cholera,  or  make  it  the  topic  of  conversation. 
Fear  and  all  the  depressing  passions  are  injurious. 

2.  Do  not  take  brandy;  it  is  not  a  preventive,  and  it  does  harm  by 
disordering  the  action  of  the  stomach  and  bowels. 

3.  Do  not  make  any  change  in  your  usual  diet,  if  it  is  simple  and  of 
easy  digestion;  take  it  moderately,  and  at  regular  intervals,  as  long  fasting 
is  injurious.     Carefully  avoid  excess  in  any  intoxicating  beverage. 

4.  Avoid  excessive  "fatigue.  If  overheated,  beware  of  any  sudden  chill, 
and  see  that  the  skin  is  kept  comfortably  warm.  If  the  disease  appears 
in  winter,  much  benefit  may  be  derived  from  wearing  a  flannel  belt  round 
the  body,  covering  the  stomach  and  bowels. 

5.  As  soon  as  cholera  appears  in  a  town,  a  bottle  of  acidulated  solution 

'  Glasgow  Medical  Joiu-nal,  1866. 


37G 


ASIATIC  CHOLERA. 


of  morphine  or  laudanum  or  paregoric,  and  a  graduated  measure  should 
be  kept  in  every  house,  place  of  business,  factory,  or  wherever,  in  fact, 
there  are  a  number  of  people  gathered  together.  Persons  traveling  should 
always  have  it  with  them,  easy  of  access.  During  the  prevalence  of  an 
epidemic,  one  intelligent  person  in  each  factory,  etc.,  should  take  charge 
of  the  health  of  the  inmates,  acting  in  the  quasi  capacity  of  "  house- 
-physician,"  and  urgiiig  all  under  his  or  her  care  to  at  once  attend  to  the 
slightest  relaxation  of  the  boAvels.  He  should  warn  them  that  absence  of 
pain  does  not  signify  absence  of  danger. 

6.  Should  tlie  slightest  diarrhoea  occur,  the  individual  so  attacked 
should  receive  at  once  the  appropriate  quantity  marked  on  the  bottle  as 
corresponding  to  his  age.  The  person  attacked  should  be  at  once  con- 
sidered a  patient,  and  conveyed  home,  placed  in  bed,  and  kept  warm.  If 
chilled,  warm  water  bottles  should  be  put  to  the  feet.  If  the  first  dose  of 
the  "cholera  mixture''  has  not  checked  the  looseness,  the  patient  should 
take  a  second  after  an  interval  of  from  one-half  to  one  hour,  A  flannel 
cloth  dipped  in  turpentine  or  essence  of  peppermint  may  also  be  placed 
all  over  the  stomach  and  bowels  for  from  forty  minutes  to  an  hour;  or  a 
large,  soft,  Avarni  poultice  of  linseed  meal  and  mustard  for  one  or  two 
hours.  Medical  assistance  should  be  summoned  if  the  diarrhoea  has  not 
promptly  yielded.  In  the  meantime  a  third  and  last  dose  of  the  medicine 
may  be  taken,  one  or  two  hours  after  th'  second  one. 

7.  It  is  well  for  the  patient  to  remain  very  quiet,  preferably  in  bed  for 
two  or  three  days  after  the  diarrhoea  is  checked.  This  is  to  be  strongly 
urged,  for  the  patient  often  feels  so  well  that  he  objects  to  remain  in  bed. 

8.  To  relieve  thirst,  a  piece  of  ice  may  be  given,  or  a  mouthful  of  iced 
water,  or  plain  soda  water.  In  some  cases,  even  more  fluid  can  be  taken  at 
a  time;  but  it  should  then  be  directed  by  the  physician.  All  food  should  be 
abstained  from  for  from  fifteen  to  eighteen  hours  after  the  medicine  has  been 
taken.  Afterward  the  diet  should  for  two  or  three  days  consist  of  such  food 
as  rice,  sago,  arrowroot,  Indian  corn  flour,  tea  and  toast,  and  similar  bland 
substances.  About  the  third  day  broths,  chicken  soup,  or  beef  tea  may 
be  taken.  Condiments,  such  as  pepper,  salt,  cinnamon,  etc. ,  are  useful. 
Green  tea  is  more  astringent  than  black. 

9.  These  rules  are  for  the  first  stage,  and  for  it  onhj,  namely,  the  cliar- 
rhcea.  If  a  person  has  neglected  the  first  warning,  and  is  in  the  second 
stage,  having  cramps,  vomiting,  and  stools  like  rice-water,  without  smell, 
the  patient  should,  until  medical  assistance  arrives,  be  placed  in  bed 
between  blankets  and  surrounded  with  bottles  of  hot  water.  He  may 
receive  a  little  ice  or  an  occasional  mouthful  of  cold  water.  The  limbs 
may  be  rubbed,  but  not  too  violently,  with  some  liniment,  quickly  pro- 
curable. '     No  medicine  is  to  be  given  until  the  arrival  of  the  doctor. 

If  the  invasion  of  cholera  is  not  preceded  by  the  mild  manifestations 
of  simple  diarrhoea,  but  begins  at  once  with  watery  purging,  the  above  plan 
may  require  certain  modifications  and  additions  that  must  necessarily 
again  vary  with  the  abruptness  and  severity  of  the  onset.  In  order  to 
insure  quiet,  overcome  pain,  and  perhaps  quickly  influence  the  bowels,  it 
is  best  to  administer  hypodermically  from  six  to  fifteen  minims  of 
Magendie's  solution  of  morphine.  If  it  be  found  desirable  to  maintain  the 
action  of  the  drug,  laudanum  in  spice  water,  or  paregoric,  may  then  be 

'  If  there  is  time,  an  opium  liniment  may  be  made  witli  one  or  two  ounces  of 
laudanum,  one  ounce  of  soap  liniment,  and  an  ounce  or  two  of  cologne  water.  It 
is  very  efficacious  and  agreeable. 


TREATMENT   OF   FIRST  STAGE.  377 

used.  But  sliould  the  stomach  prove  rebellious  to  the  laudanum,  hypo- 
dermics may  be  from  time  to  time  repeated,  the  quantity  being  adjusted 
to  the  varying  indications  of  the  particular  case,  but  rarely  again  reaching 
tne  maximum  of  the  initial  dose.  Bed-rest  is  absolutely  necessary  now, 
and  indeed,  as  a  rule,  the  patient's  general  malaise  will  not  incline  him 
to  disobey  orders.  It  is  advisable  to  place  a  large  poultice  made  of  equal 
proportions  of  ground  mustard  and  flaxseed  meal  over  the  entire  abdomen, 
and  after  decided  reddening  of  the  skin,  replace  it  by  ordinary  poultices, 
opium  liniment  on  cotton  flannel,  warm  flannel  alone,  or  simply  a  hydro- 
pathic bandage,  fitting  snugly  but  not  uncomfortably  around  the  abdomen. ' 
The  latter  especially  often  gives  the  patient  a  sensation  of  grateful  ease 
that  it  is  very  desirable  to  maintain. 

Vomiting  may  still  be  absent,  or,  when  present,  it  may  be  possible  to 
restrain  or  suppress  it  by  allowing  small  bits  of  cracked  ice,  cold  cham- 
pagne, or  simple  water  charged  with  carbonic  acid.  Drop  doses  of  the 
wine  of  ipecac,  or  1  to  3  grain  doses  of  oxalate  of  cerium,  may  likewise  aid 
in  controlling  the  vomiting.  If  the  patient  now  grows  very  thirsty,  there 
is  no  objection  to  allowing  him  to  drink  plain  water,  that  it  is  well  to  have 
previously  boiled,  then  cooled,  shaken  and  iced.  Claret  or  small  quantities 
of  brandy  or  whisky  may  also  be  added  to  the  Avater,  but  need  not  be 
forced  ujDon  the  patient.  It  does  not  seem  advisable  to  allow  the  imbibi- 
tion of  large  quantities  of  liquid  at  one  time.  Small  quantities  given  at 
short  intervals  answer  much  better.  Any  attempt  to  prevent  collapse  by 
using  large  quantities  of  alcoholic  stimulants  is  decidedly  reprehensible. 

Small  quantities  of  tea -punch,  hot  or  cold,  preferably  hot,  made  of 
green  tea,  arrack,  or  some  other  nice  light  spirits,  to  wliich  the  rich  can 
add  champagne,  makes  a  light  and  digestible  drink  which  will  Avarm, 
without  overstimulating.  Vermouth  wine,  which  is  merely  a  light  white 
wine,  flavored  with  aromatic  and  slightly  bitter  herbs  is  excellent.  Sour  and 
Elihie  wine  is  better  than  heavy  sherry,  which  should  not  only  be  pure, 
but  diluted  with  water;  10  per  cent,  of  alcohol  is  as  sti'ong  as  any  wine  or 
diluted  spirits  should  be  used.     (Peters). 

Although  cholera  patients,  as  a  rule,  crave  cold  fluids,  it  is  neverthe- 
less worthy  of  remembrance  that,  in  some  cases,  hot  weak  tea,  or  pepper- 
mint water  or  simply  very  hot  water,  is  borne  better  than  iced  drinks, 
and  may  be  used  in  place  of  them.  In  this  connection  it  is  perhaps  de- 
serving of  notice  that  ]\Iacnamara  and  several  other  competent  writers 
urge  aljstinence  from  all  fluids.  They  rely  solely  on  the  use  of  bits  of  ice, 
allowing  the  patients  an  unlimited  supjjly  of  this  cooling  substance.  On 
the  other  hand,  Macpherson  from  his  own  experience  in  one  of  the  severest 
cases  of  cholera  on  record  which  recovered,  says  he  will  never  deny  a 
cholera  patient  a  reasonable  amount  of  water,  either  plain  or  carbonated. 

Any  other  symptoms  arising  at  this  period  call  merely  for  cautious 
treatment  directed  toward  their  mitigation,  but  all  "  meddlesome  inter- 
ference "  is  very  much  to  be  deprecated.  Xothing  seems  to  the  writer's 
mind  more  irrational  than  to  attempt  by  potent  and  varied  drugs,  frequently 
given  in  large  quantities,  combined  with  the  use  of  harassing  external 
measures,  to  do  battle  against  a  foe  that  in  many  cases  is  clearly  beyond 
the  reach  of  all  treatment. 

The  following  table  is  based  on  800  cases  of  cholera  treated  in  the  prov- 
inces throughout  England  and  Scotland  in  1854,  and  represents  the  percent- 

'  Flanaels  wnmg-  out  in  hot  cayenne  jiejiper  water  are  also  usel'ul. 


Per  cent. 

Or,  including 

deaths    as 

failures. 

59.0 

59.0 

41.9 

41.9 

25.0 

25.0 

34.0 

25.3 

18.9 

22.0 

16.0 

21.8 

13.8 

ir.i 

11.2 

14.0 

8.G 

13.  r 

3.G 

5.0 

2.6 

4.0 

37g  ASIATIC  CHOLERA. 

age  of  failure,  after  the   use   of  various   remedies   in  premonitory   diar- 
rhcea:  ' 


Catechu,  kino,  etc.,         .... 

Salines,  ...... 

Eliminants,     ...... 

Calomel,  ...... 

Calomel  and  opium,         .... 

Stimulants,     ...... 

Chalk  and  opium,    ..... 

Acetate  of  lead  and  opium, 
Opium,    .  '       . 

Chalk  mixture, 

Sulphuric  acid  and  opium. 

Having  thus  briefly  outlined  the  simple  management  of  premonitory 
diarrhoea  and  cholerine,  we  Avill  next  turn  our  attention  to 

The  Treatment  of  Well-marked  Cholera. — Although  we  have 
re])eatedly  expressed  ourselves  to  the  eifect  that  we  have  practically  no 
power  to  always  arrest  a  fully-developed  attack  of  Asiatic  cholera,  never- 
theless the  principles  which  should  guide  the  physician's  recommendations 
and  actions  seem  to  us  to  be  plain  and  unequivocal.  The  enforcement  or 
even  encouragement  of  any  rigid  theoretical  plan  of  dealing  Avith  the  un- 
fortunate subjects  of  a  pronounced  attack,  seems  utterly  reprehensible. 

As  in  other  diseases,  so  too  in  cholera,  the  most  reliable  indications  for 
medical  interference  are  furnished  by  a  knowledge  of  the  disease-processes 
underlying  the  symptoms  observed  by  the  physician.  Accordingly, -if  it 
becomes  evident  that  the  normal  absorbent  functions  of  the  gastro-intestinal 
surfaces  are  completely  reversed,  it  is  worse  than  useless  to  introduce  large 
quantities  of  powerful  drugs  and  stimulants  either  from  above  or  (as  has 
been  quite  recently  often  done)  from  below.  We  say  worse  than  useless, 
for  the  reason  that  the  uncertainty  in  duration  of  the  different  stages  of 
cholera  makes  it  possible  for  reaction  to  occur  with  enough  medicine  or 
alcohol,  or  both,  in  the  alimentary  canal  to  kill  the  weakened  jiatient  by 
suddenly  acting  upon  his  system  immediately  after  the  rapid  revival  of 
absorption.  There  is  not  the  slightest  doubt  that  sudden  death,  so  fre- 
quently observed  shortly  after  apparent  reaction,  has  been  due  in  some 
instances  to  such  causes.  The  oral  administration  of  drugs  is,  therefore, 
only  indicated  while  intestinal  absorption  continues.  Again,  the  subcuta- 
neous connective  tissue  so  quickly  shrinks  during  collapse  that  its  power 
of  absorbing  is  largely  reduced  or  completely  suspended.  ^  Nevertheless 
whenever  potent  remedies  are  demanded,  hypodermic  injection  offers  a 
better  chance  of  effective  medication  than  the  swallowing  of  mixtures, 
pills,  or  powders,  and  also  than  the  much  vaunted  enteroclysis  of  Cantani 
and  other  recent  Italian  writers. 

Knowing  then  that  the  internal  use  of  drugs  during  collapse  is  of  no 
avail,  it  seems-  unnecessary  to  enumerate  the  countless  host  of  remedies 

'  General  Board  of  Health.  Report  on  the  Results  of  the  Different  Methods  of 
Treatment,  by  the  Treatment  Committee  of  the  Medical  Council,  1855. 

■^  Still  subcutaneous  injections  of  weak  acid  water,  or  even  of  salt  and  water, 
have  at  times  appeared  to  stem  the  tide  of  outflow  from  the  bowels,  as  tonics  and 
astringents  acting  from  behind.    Compare  also  Hayem's  views  in  next  chapter. 


TREATMENT  OF  PRONOUNCED  CHOLERA.         379 

that  have  been  and  continue  to  be  recommended  by  writers  of  all  nation- 
alities. 

Before  the  occnrrence  of  collapse,  and  during  the  stage  of  profuse  dis- 
charges it  is  generally  advisable  to  administer  small  doses  of  morphine 
hypodermically.  This  may  at  least  to  some  extent  quiet  the  patient  and 
diminish  his  sufferings.  But  the  drug  should  never  be  "pushed,"  as  for  ex- 
ample is  commonly  done  in  peritonitis.  For  the  relief  of  persistent  thirst 
small  quantities  of  iced  fluids,  such  as  plain  water,  carbonic  acid  Avater  and 
especially  water  weakly  acidulated  with  mineral  acids  or  freshly  expressed 
lemon  juice,  and  similar  drinks,  may  be  frequently  given.  Little  bits  of 
ice  taken  every  few  minutes  are  also  allowable. 

Some  writers  have  insisted  on  completely  withholding  these  harmless 
and  grateful  beverages,  believing  that  they  increased  vomiting  and  favored 
the  intestinal  flux.  But  there  is  not  the  slightest  foundation  for  enter- 
taining such  an  opinion.  Indeed,  it  would  be  downright  cruelty  to  refuse 
the  momentary  relief  that  cool  drinks  often  give  the  patient.  It  is  only  too 
triie  that  thirst  is  not  quenched  thereby,  and  that  the  stomach  may  imme- 
diately reject  the  eagerly  swallowed  liquid. 

Yet  in  some  cases  the  relief  is  so  apparent  that  we  have  no  hesitation 
in  affirming  it  to  be  the  physician's  duty  to  see  that  drinks  are  not  with- 
held. In  well-marked  collapse  it  is  best  to  stop  all  medication.  More- 
over, in  this  condition  heat  applied  to  the  body,  frictions,  embrocations, 
and  similar  well-known  measures  have  no  power  to  call  back  to  the  surface 
the  fast-ebbing  tide  of  warmth.  But  before  that  time  such  measures  may 
be  employed  to  advantage.  Semmola  has  strongly  urged  the  warm  bath, 
repeated  every  two  or  three  hours  as  a  possible  preventive  of  collapse. 
Yet  this  must  often  be  fatiguing  and  injurious.  He  admits  also  that  to 
bathe  a  patient  during  collapse  would  have  no  more  effect  than  to  deal 
similarly  with  a  corpse.  But  on  the  other  hand  he  insists  that  the  warm 
bath  has  a  calmative  effect,  and  a  rallying  influence,  especially  noticeable 
in  the  stage  of  premonitory  diarrhoea. 

Dr.  J.  C.  Peters  has  used  pieces  of  unslaked  lime,  wrapped  in  wet 
clothes  and  put  in  bowls  under  the  bedclothes  successfully  in  incipient 
collapse.  The  heat  produced  is  very  great  and  grateful,  and  there  may 
possibly  be  some  disinfecting  power  in  this  process.  A  pack  in  blankets 
wrung  out  in  hot  cayenne  or  mustard  water  is  useful;  and  it  is  very  easy 
when  the  blankets  cool  or  dry  off,  to  pour  very  hot  water  upon  them  without 
removing  them  or  disturbing  the  patient.  Slaking  lime  used  in  the  way 
just  mentioned  is  easy  of  application  and  does  not  tire  or  weaken  or  disturb 
the  patient. 

An  energetic  doctor  once  gave  his  collapse  patients  a  hot  bath,  made 
them  drink  all  the  hot  water  their  stomachs  would  hold,  and  then  pumped 
not  only  their  bowels  but  their  bladder  full  of  hot  water,  and  complacently 
said  if  any  one  could  do  more  to  warm  a  patient  up  he  would  like  to  hear 
of  it.     We  can  only  add,  slaking  lime  in  bed.     (Peters). 

We  will  return  to  Semmola's  views  on  the  treatment  of  cholera  later 
on,  merely  mentioning  here  that  the  temperature  of  the  Avater  used  for 
the  baths,  as  recommended  by  him,  should  not  fall  below  100°  F.,  nor  much 
exceed  104°  F.  If  the  muscular  cramps  prove  rebellious  to  gentle  frictions 
with  warm  flannels  or  slightly  stimulating  or  anodyne  liniments,  if  they 
remain  uninfluenced  by  a  hypodermic  injection  of  morphine,  the  physician 
may  allow  the  inhalation  of  chloroform  carried  to  the  point  of  partial  an- 
aesthesia.    This  may  be  repeated  from  time  to  time  without  fear  of  disas- 


380  ASIATIC  CHOLERA. 

trous  effects  on  tlie  heart.     But  unless  tliorouglily  reliable  and  competent 
trained  nurses  be  in  waiting,  the  attending  or  some  other  physician  nui^t 
personally  direct  its  administration. 
Dr.  Maclean  '  says  that: 

Cramps  are  best  relieved  by  the  use  of  clilorofonii,  given  in  closes  of  five  or  six 
minims  in  a  little  water,  and  if  vomiting  be  excessive  a  little  may  be  sprinkled 
on  a  pad  of  lint  covered  with  oiled  silk  or  gutta-percha  tissue  and  applied  to  the 
epigastrium;  or  spongio-piline  may  be  used  for  tlie  purj^ose.  I  have  used  chloro- 
form in  this  wixy  both  externally  and  internally,  vei-y  freely,  and  always  with 
good  efi'ect. 

Dr.  Macnamara  speaks  strongly  in  favor  of  chloroform.  Having 
pointed  out  the  great  importance  to  the  patient  of  procuring  rest,  he  says: 
' '  In  furtherance  of  this  latter  object,  I  know  of  no  remedy  more  efficacious 
than  chloroform.  If  the  patient  is  in  much  pain  and  very  restless,  I 
strongly  advise  his  being  placed  under  the  influence  of  this  anfesthetic. 
The  chloroform  must  be  administered  by  inhalation,  and  its  full  effects 
maybe  safely  induced;  or  at  any  rate  we  may  put  the  patient  into  a  sound 
and  comfortable  sleep.  .  .  .  We  must  be  prepared  to  continue  the 
action  of  the  chloroform,  perhaps  for  four  or  five  hours,  or  even  longer, 
according  to  circumstances." 

Dr.  Parrot  ^  also  favors  the  employment  of  chloroform  in  cholera.  He 
used  one  to  two  drachms  of  chloroform  daily  in  severe  cases,  and  less  in 
mild  ones.  The  vehicle  was  water  100  grammes,  and  syrup  of  quinine 
twenty  grammes.  This  mixture  was  given  in  tea,  a  tablespoonf  ul  every 
half  hour;  at  the  same  time  iced  beef -tea  was  given  vei-y  frequently  in 
small  quantities.  Warmth  Avas  applied  to  the  skin,  and  dry  and  stimulating 
frictions  were  used.  Chloroform  given  in  this  way  calmed  the  anxiety 
and  epigastric  pain,  and  seemed  to  diminish  the  frequency  of  the  vomitings, 
which  were  also  less  painful. 

Dr.  Hartshorne,^  in  1854,  spoke  as  follows  concerning  the  use  of  chlo- 
roform : 

Experience  has  shown  that,  taken  into  the  stomach,  it  is  as  totally  free  from 
danger  as  any  otiier  drug;  and  its  employment  is  destined  to  be  yet  much  more 
widely  extended;  a  fluid-drachm  of  chloroform  taken  by  the  stomaci)  is  not  more 
than  equal,  in  soporofic  effect,  to  thirty  or  thirty-five  drops  of  laudanum.  In  doses 
of  fifty  to  seventy-live  drops  (about  fifteen  minims),  I  have  given  it  every  half 
horn-  for  several  hours  together.  It  differs  from  the  opiate  preparations  in  the 
promptness  of  its  hypnotic  action,  the  much  shorter  period  of  its  duration,  a  less 
degree  of  cerebral  oppi-ession,  and  the  absence  of  all  stimulus  to  the  circulation.  It 
might  be  called  a  "  diffusible  narcotic,"  comparing  in  this  respect  with  opium  as 
animonia  does  with  alcohol.  To  produce  much  effect  with  it,  repeated  doses  at 
sliort  intervals  will  be  necessary.  Its  pungent  property  causes  it  to  require  plenti- 
ful dilution,  w^hich  is  of  course  facilitated,  by  the  action  of  some  demulcent.  Per- 
haps the  orgeat  syrup  is  the  best.  Every  fluid  drachm  of  chloroform  should  have 
at  least  two' fluid  ounces  of  water  Avith  it  when  taken;  and  it  will  need,  if  in  ordi- 
narv  gum  mucilage,  considerable  agitation  to  re-suspend  the  particles  immediately 
before  bwallowing.  When  taken  in  aqueous  mixture  alone,  however,  unless  in 
verv  small  doses,  it  produces  nausea  with  some  persons.  This  is  entirely  pre- 
vented bv  the  addition  of  a  strong  aromatic,  or  still  better  by  giving  the  chloroform 
in  aromatic  tincture.  From  the  ready  solution  and  kindred  action  of  camphor  witli 
chloroform, their  combination  has  become  a  very  common  one.  For  manj'  purposes, 
however,  a  still  better  preparation  is  a  sort  of  chloroform  paregoric,  or  compound 


1  Lectures  on  the  Treatment  of  Cholera,  by  Deputy  Inspector-General  Maclean, 
M.  D.,  Professor  of  Military  Medicine.     London  Lancet,  Feb.  3d  and  17th,  1866. 
-  Gazette  hebdomadaire,  December  8,  I860. 
^  American  Journal  of  Medical  Sciences,  January,  1854. 


TEEATMEXT  OF  PRONOUNCED  CHOLEEA.         38J^ 

tincture  of  chloroform,  e.g.  5.  Chloroform,  f  3  ij;  sp.  camph.  et.  tinct.  opii,  aa 
f3iss:  ol.  cinnamon,  gtt.  viij:  alcohol,  f  3  iij-  M.  et  fiat  tinctura.  Dose,  from 
five  to  thirty  minims,  or  more,  as  required.  The  most  admirable  effects  have 
been  witnessed  from  the  administration  of  chloroform,  as  above  combined,  in 
malignant  cholera. 

Eecently  Dr.  M.  Desprez '  has  also  advocated  the  employment,  both 
externally  and  internally,  of  chloroform.  He  believes  that  by  this  means 
from  80  to  90  out  of  ever}'  100  persons  in  the  algid  stage  of  cholera  could 
be  saved.  He  bases  this  extravagantly  hopeful  view  on  his  own  experience 
and  on  tliat  of  other  physicians  in  Asia  Minor,  India  and  Cochin  China. 
The  following  is  his  formula: 

Chloroform 1  gram  (15  minims) 

Alcohol 8  grams  (2  drachms) 

Acetate  of  Ammonia  ...  10  grams  (21  drachms) 

Syrup  of  hydrochlorate  of  morphia       .  40  grams  (1^  ounce) 

Water  ......  110  grams  (3-1  ounces) 

Dose:  A  tablespoonful  every  half  hour. 

Without  sharing  Desprez 's  sanguine  views, we  nevertheless  have  reason  to 
believe  that  chloroform  may  often  be  used  with  advantage,  especially  for  pur- 
poses of  inhalation.  But  ether  is  objectionable,  and  nitrite  of  amyl  either 
inhaled  or  injected  beneath  the  skin  has  not  realized  the  expectations  that 
Avere  formed  concerning  it. 

Another  common  symptom  that  may  become  so  distressing  as  to 
require  the  inhalation  of  chloroform  is  singultus.  But  before  having  re- 
course to  this  means,  the  hji^odermic  use  of  morphine,  an  epigastric 
sinapism,  a  spice  poultice  or  a  blister  should  be  tried  to  stop  the  hiccough. 
Where  there  is  reason  to  believe  that  a  limited  amount  of  absorption  still 
takes  place  in  the  alimentary  canal,  various  stimulants  may  be  administered 
in  a  tentative  Avay,  in  order  to  secure  the  prevention  of  collapse.  Alcoholic 
beverages,  such  as  Burgundy,  Tokay  wine,  port  wine,  brandy  and  water, 
or  champagne,  may  then  be  given.  In  the  same  Avay,  if  indicated  by  the 
condition  of  the  patient,  various  excitants  such  as  the  ammoniacal  prepa- 
rations, camphor  and  musk  may  be  employed.  But,  as  jDreviously  pointed 
out,  if  collapse  comes  on  in  spite  of  their  moderate  exhibition,  they  should 
be  at  once  discontinued.  Even  then  an  attempt  to  stimulate  cardiac 
action  by  the  hypodermic  use  of  similar  medicaments,  including  brandy 
and  ether,  may  be  made.     But  this  too  must  not  be  i:)ersisted  in. 

Obviously  it  is  impossible  to  lay  down  fixed  rules  for  the  guidance  of 
the  practitioner  in  this  direction'.  But,  as  already  stated,  the  general 
principles  governing  intelligent  action  are  by  no  means  as  obscure  as 
might  be  supposed  from  the  confused  and  conflicting  statements  of  many 
authors. 

The  writer  may  be  permitted  to  say  here  that  he  strongly  deprecates 
the  blind  tapping  about  among  various  supposed  remedies,  in  the  vain 
hope  that  a  lucky  accident  may  result  in  the  discovery  of  a  really  curative 
agent.  The  physician  should  make  every  honest  effort  to  stay  the  march 
of  the  disease  by  employing  those  means  the  action  of  which  he  is  familiar 
with.  But  to  use  the  living  bodies  of  cholera  patients  as  suitable  material 
for  blind  pharmacological  and  other  experimentation  seems  to  the  writer  as 
irrational  as  it  is  inhuman;   nevertheless  perhaps  in  desperate  cases  ap- 

'  Du  Traitement  Rationnel  de  la  Periode  aigue  du  Cholera  Asiatique.     Paris, 

1S84. 


382  ASIATIC  CHOLERA. 

parently  desj^erate  means  are  allowable,  provided  always  tliey  be  neither 
cruel  nor  irrational. 

Treatment  During  Reaction. — If  the  patient  rallies  from  his  col- 
lapse and  enters  with  a  flickering  flume  of  uncertain  life  upon  the  period 
of  reaction,  the  great  value  of  careful  nursing  and  strict  diet  is  if  anything 
more  ajjparent  than  ever  before.  Drugs  avail  little  or  nothing.  Small 
doses  of  opium  are  sometimes  given  with  advantage,  but  as  a  general  thing 
the  patient  Avill  fare  better  without  narcotics.  Solid  foods  are  absolutely 
dangerous.  Fluids,  however,  may  be  allowed  somewhat  liberally.  Milk 
at  first  diluted  with  jDlain  water,  or  carbonic  acid  water,  egg-water,  decoc- 
tions of  arrowroot,  sago,  or  rice  well-strained  and  seasoned  with  plenty  of 
salt,  are  all  to  be  commended.  After  a  few  days,  broths  and  soups  thick- 
ened with  oatmeal,  rice,  barley,  or  farina  may  be  allowed.  Coffee  and  tea 
may  now  also  be  permitted  in  a  more  concentrated  form.  Gentle  stimu- 
lation by  generous  wines  will  be  found  necessary  in  many  cases.  Only 
very  gradually,  however,  can  a  diet  consisting  of  soft-boiled  eggs,  meats, 
concentrated  soujjs,  bread  and  potatoes  be  resumed. 

Relapses  are  to  be  treated  with  the  same  caution  and  on  the  same 
principles  as  the  primary  attack.  AVlien  it  is  remembered  that  the  brunt 
of  the  battle  had  to  be  borne  by  the  gastro-intestinal  tract,  the  pedantic 
supervision  of  the  patient's  diet  will  appear  ]iot  only  pardonable  but  abso- 
lutely essential. 

Again  in  the  Management  of  Complications  and  Sequelae,  the 
fact  should  not  for  a  moment  be  lost  sight  of,  that  just  as  in  typhoid  fever, 
so  too  in  cholera,  the  healing  of  intestinal  lesions  must  not  be  jeopardized 
by  a  careless  allowance  of  too  much  or  improper  food.  Lebert  says  truly, 
"  Indigestion  is  as  fatal  in  the  convalescence  of  cholera  as  in  typhoid  fever." 

Having  pointed  out  the  necessity  of  keeping  in  mind  the  weakened 
condition  of  the  gastro-intestinal  apparatus,  it  apj)ears  unnecessary  to 
burden  this  account  with  detailed  du-ections  concerning  the  treatment  of 
the  various  morbid  states  that  complicate  or  follow  an  attack.  The  in- 
telligent pi-actitioner  will  apply  the  same  general  principles  to  this  task 
that  guide  him  in  the  management  of  those  conditions  when  not  connected 
with  cholera. 

The  typhoid  stage  is  properly  a  complication  or  sequel  of  the  period 
of  attack,  and  a  more  or  less  profound  renal  disturbance  is  generally  the 
dominant  symptom  of  that  condition.  If  hot  drinks  and  the  induction 
of  perspiration  by  the  use  of  the  wet  pack  and  warm  blankets  do  not 
relieve  the  kidneys,  it  is  only  exceptionally  proper  to  try  more  energetic 
remedies,  such  as  diuretics  and  pilocarpine.  If  the  patient  does  not  pass 
any  urine  within  thirty-six  hours  after  reaction  has  commenced,  Macna- 
mara  is  in  the  habit  of  prescribing  the  tincture  of  can  tliar ides  as  recom- 
mended by  Dr.  Francis.  He  gives  ten  minims  in  an  ounce  of  water  every 
half  hour  until  six  doses  have  been  taken.  He  adds:  "  If  this  treatment 
does  not  cause  urine  to  pass,  we  must,  after  the  sixth  dose,  discontinue 
the  medicine  for  twelve  hours,  and  then  repeat  it  in  precisely  the  same 
way,  giving  six  doses  more,  ten  minims  each.  ...  I  have  seen  this 
treatment  followed  by  the  most  satisfactory  results  in  very  man)^  cases." 
Finally  the  cautious  exhibition  of  digitalis,  which  is  also  a  heart-tonic, 
should  not  be  overlooked  at  this  period. 


USELESS  DRUGS  AND  MEASURES.  333 


CHAPTER   XLIV. 

SPECIAL  METHODS  OF  TREATMENT  AND  PROTECTIVE  INOCULATION. 

Having  sketched  in  the  preceding  chapter  a  plan  of  treatment  which 
the  editor  believes  to  be  simple,  rational,  and  based  as  well  upon  the 
present  state  of  onr  knowledge  regarding  cholera  as  upon  former  thera- 
peutical experiences,  we  are  now  prepared  to  examine  some  of  the  methods 
of  treatment  advanced  by  other  writers.  Especially  those  therapeutical 
recommendations  which  are  of  more  recent  date  may  be  of  sufficient  in- 
terest or  novelty  to  warrant  our  attention.  Although  it  is  not  intended 
to  give  a  complete  resume  of  modern  therapeutics,  nevertheless  all  the 
more  important  writings  will  be  considered.  Following  the  general  plan 
of  this  volume,  it  has  been  deemed  expedient  to  abstain  from  lengthy 
criticism,  so  that  whenever  comment  seemed  really  called  for,  it  has  been 
made  in  the  briefest  manner  compatible  with  the  clear  expression  of  the 
editor's  personal  views. 

Writing  as  long  ago  as  18G0,  Drasche  showed  that  the  more  or  less  en- 
thusiastic claims  advanced  in  favor  of  the  curative  power  of  many  remedies 
and  methods  of  treatment  had  not  stood  the  crucial  test  of  time,  and  had 
nothing  in  their  favor  save  the  warm  recommendations  of  their  respective 
advocates.  The  enumeration  made  at  that  time  may  be  repeated  with  ad- 
vantage at  the  present  day,  as  it  is  curious  to  note  how  tenaciously  some 
of  the  older  remedies  are  still  clung  to  in  many  quarters.  The  first 
measure  to  be  mentioned  is  venesection.  This  was  practiced  at  one  time 
in  a  routine  way  by  most  Indian  physicians. ' 

Next  comes  the  exhibition  of  calomel,  also  first  advised  by  Indian 
practitioners.  Searle,  Annesley,  Johnson  and  others  employed  the  drug  in 
quantities  of  about  twenty  grains  repeated  hourly  until  the  stools  looked 
green.  Later  on  it  was  employed  in  smaller  doses.'  Drasche  condemns 
its  use  altogether. 

-  On  the  subject  of  venesection  in  cholera,  Stille  says:  "There  was  a  time  when 
certain  j^liysicians,  carried  away  by  conceptions  of  the  disease  evolved  from  their 
inner  consciovisness,  maintained  that  it  consisted  essentially  of  a  spasm  of  the 
blood-vessels,  and  that  the  natural  and  legitimate  cure  for  it  was  to  be  found  in 
bleeding.  No  theory  is  so  gratuitous  or  absurd,  but  cases  may  be  found  which  ap- 
pear to  justify  it,  and  in  this  instance  also  examples  were  not  wanting  to  illustrate 
at  once  the  truth  of  the  theory  and  its  successful  application.  Longer  experience, 
however,  and  a  more  correct  conception  of  the  disease,  have  long  since  condemned 
this  metliod,  which  was  almost  as  dangerous  as  it  was  irrational." 

'■^  Stille,  in  referring  to  the  treatment  of  Asiatic  cholera  by  mercurials,  especially 
according-  to  the  metliod  of  Ayre,  has  so  well  expressed  the  views  that  are  now 


384  ASIATIC  CHOLERA. 

Ipecacuanha — Drasclie  asserts  that  this  drug  produces  no  alterative 
effect  upon  tlie  intestinal  tract.  He  denounces  the  eliminative  method  in 
Avhatever  way  its  action  is  obtained.  "Whether  emetics  or  laxatives  be 
used,  the  effect  is  always  injurious. 

Alkaline  carbonates,  as  recommended  by  Hamburger,  Maxwell,  Mack- 
intosh and  others,  are  useless. 

Spirits  of  ammonia  (Steart),  liquor  ammon.  (Ebers),  are  useless  or  in- 
jurious. 

Carbon  trichloride,  used  by  Troschel,  Simon  and  other  Berlin  j^hysicians, 
is  superfluous.  Keinhardt  and  Leubuscher  found  it  a  rather  useful  ex- 
citant. Henoch  and  Lebert,  however,  showed  that  in  grave  cases  it  was 
quite  useless.  The  following  drugs  also  belong  to  the  category  of  remedies 
of  doubtful  utility,  and  in  fact  Drasche  believes  that  they  should  be 
withheld.  Fuming  nitric  acid  (Hope,  Bowes,  Prchal),  bismuth,  niti'atc 
of  silver  (Lever),  strychnia  (Abeille),  phosphorus  (Paul)  aqua  calcis 
(Pasquali,  Siemerling),  valerianate  of  ammonia  (Oettinger),  liydrated  oxide 
of  iron  (Heigl),  sulphuric  acid,'  manganic  acid,  pyroligneous  acid  (Biertz), 

entert<iined  by  the  majority  of  competent  writers  that  we  cannot  do  better  thiin 
liere  quote  his  words.     He  says: 

"It  is  now  conceded  by  all  enlightened  physicians  that  mercurials  in  large  or 
in  ordinary  doses  are  worse  than  worthless  in  epidemic  cholera.  In  1832,  Dr.  Ayre 
of  Hull,  England,  proposed  another  method  of  using  calomel,  to  which  he  adhered 
in  treating  this  disease.  It  consisted  in  the  administration  of  very  small  doses  of 
calomel  at  short  intervals,  and  with  each  of  the  lirst  doses  a  few  drops  of  laud- 
anum. Such  a  method,  if  not  carried  too  far,  certainly  has  the  merit  of  sparing- 
the  patient  a  great  deal  of  the  perturbative  treatment  against  which  we  have,  in 
the  preceding  pages,  protested.  But  that  was  not  at  all  the  notion  of  its  pro- 
poser. He  claimed  for  it  positive  and  active  virtues.  He  stated,  as  the  funda- 
mental ground  of  his  plan,  that  'the  primary  and  leading  object  of  the  treatment 
must  be  to  restore  the  secretion  of  the  liver.'  He  did  not  in  the  least  doubt  that 
he  was  able  to  do  this  by  the  administration  of  mercury — not,  indeed,  by  a 
direct  action  upon  the  liver  itself,  but  indirectly  and  syiupathetieally  through  the 
stomach,  and  by  the  healthy  and  specific  stimulus  imparted  to  it,  by  which  the 
due  secretion  of  the  bile  is  promoted.  It  is,  indeed,  difficult  to  conceive  of  any 
stimulus  that  calomel  could  impart  to  the  stomach  that  would  not  be  equally 
given  by  any  otlier  non-irritant  and  insoluble  powder — subnitrate  of  bismuth,  for 
example.  Indeed.  Ayre  himself  relates  the  case  of  a  man  who  in  an  attack  of 
cholera  took  during  three  days  no  less  than  live  hundred  and  eighty  grains  of 
calomel,  and  recovered  without  any  soreness  of  the  mouth.  But  the  plan  wiiich 
he  linalK'  elaborated  was  different.  It  was  to  give  small  doses  of  calomel  repeat- 
edly— in  the  premonitory  stage  one  grain  every  half  hour  or  hour  for  six  or  eight 
successive  times,  or,  if  this  failed,  every  five  or  ten  minvites — and  in  the  stage  of 
collapse  one  gi-ain  and  a  half  every  five  minutes.  In  a  few  cases  of  extreme 
severity  two  grains  of  calomel  were' given  ever}'  five  minutes  for  an  hour  or  two, 
and  then  the  ordinary  dose  of  one  grain  was  resumed.  But  tliis  was  not  all:  with 
every  dose  of  calomel  was  associated  one,  two,  or  throe  drops  of  laudanum,  so  that 
if  these  doses  were  repeated  frequently  the  patient  received  a  very  efiicient  amount 
of  the  narcotic  during  the  attack.  Indeed,  Ayre  attributed  to  it  the  virtue  of  sus- 
taining the  vita]  powers  under  the  depressing' intluence  of  the  disease,  and  of  re- 
moving or  abating-  the  cramps,  as  well  a.sof  retaining  thec^ilomel  in  the  stomach. 
(A  Report  on  the  Treatment  of  the  Malignant  Cholera.  London,  1888.)  From  the 
preceding  account  it  follows  that  the  treatment  of  cholera  bj'  small  doses  of  cal- 
omel with  laudanum  is  founded  on  an  erroneous  assumption  of  the  mode  of  action 
of  calomel,  and  that  whatever  efficacy  the  plan  of  treatment  may  possess  maj' 
with  more  justice  be  attributed  to  the  opium,  whose  eft'ects  we  know,  than  to  the 
calomel,  whose  action,  so  far  as  it  is  known  at  all,  has  no  conceivable  relation  to  the 
disease  for  which  it  was  given.  Howe\er  this  may  be,  if  the  results  of  Ayre"s 
treatment  are  compared  with  those  of  other  plans,  it  exhibits  veiy  little  if  any 
superiorit^^ 

'  The  utilitj'  of  sidphuric  acid  in  cholera,  properly  diluted  and  given  as  advised 


DRASCHFS  PLAN  OF  TREATMENT.  3g5 

nitre  (Stevens),  gunpowder  (Roux),  castor-oil  (Johnson),'  croton  oil 
(James),  chloride  of  lime  and  chlorinated  water  (Prchal),  chlorate  of 
potash  (Aron),  chloric  ether  (Fuller),  chloroform  (Vincent),  animal  char- 
coal (Briett),  hashish  (Villemain),  stachys  anatolica  (Fauvel),  protoxide 
of  nitrogen  and  oxygenated  water  (Thenard),  common  salt  used  in  baths 
and  clysters  (Goz)  and  for  intravenous  injections  (Dieffenbach),  intravesical 
injections  of  water  (Piorry).  inhalation  of  volatile  aromatics  (Haller),  and 
finally  the  transfusion  of  blood,  the  use  of  electricity  and  curative  gym- 
nastics. 

Drasche  is  not  a  thoroughgoing  pessimist,  however,  for  he  firmly 
believes  that  lives  may  often  be  saved  b}^  timely  and  rational  treatment  of 
a  symptomatic  kind.  The  following  account  ^  embodies  his  own  ideas  of 
the  management  of  cholera  patients: 

He  attaches  great  importance  to  a  rigid  diet  in  the  very  commencement, 
nothing  but  soups  being  allowed.  From  a  neglect  of  this  precaution,  has  arisen 
the  disappointment  which  many  physicians  have  found  in  remedies  for  the  diar- 
rhoea. Only  a  limited  quantity  of  fluids  may  be  taken,  and  this  if  possible  warm. 
If  the  thirst  is  excessive,  ice  may  be  allowed.  Patients  have  stated  that  the  use 
of  cold  drauglits  was  followed  by  marked  intestinal  rumbling,  and  soon  after  a 
watery  dejection,  in  spite  of  preventive  medicines.  His  remedy  for  the  diarrhoea 
is  ojiium,  wliich  he  prefers  to  give  in  the  form  of  tincture  (tinct.  opii.  crocata). 
Should  the  diarrhoea  continue  several  days  witliout  amendment,  astringents  should 
be  substituted  for  the  opium.  Of  these  he  pi-efere  rhatany  and  tannin  in  doses  of 
five  gi-ains  of  eacli. 

As  the  collapse  approaches,  stimulants  are  indicated,  to  excite  the  nervous 
system  and  quiclvcn  the  circulation.  He  likes  tlie  ajthereal  oils,  as  of  cinnamon, 
mint  and  juniper;  musk  has  also  a  similar  action.  If  time  presses,  diffusible 
stinmlants,  as  warm  wine,  champagne,  rum,  or  puncli,  may  be  employed.  Sul- 
phuric and  acetic  ethers  (stimulant  anti-spasmodics)  have  also  a  decided  action 
upon  tlie  cramps  and  vomiting-.  Used  for  inhalation  they  improve  the  pulmonary- 
circulation,  and  relieve  dyspnoea.  The  effect  of  ether,  thiLs  employed,  has  oftea 
been  surprising,  especially  with  young  persons.  In  a  short  time  after  the  com- 
mencement of  the  inlialation,  tlie  pulse  has  improved,  the  temperature  of  the- 
body  risen,  the  c^'ahosis  lessened,  the  cramps  have  diminished,  and  reaction  has. 
set  in. 

As  an  additional  means  of  restoring  the  circulation,  frictions  should  be  em- 
ployed, and  the  body  enveloped  in  warm  coverings.  Sinapisms  are  also  considered 
as  very  useful.  If  reaction  is  imperfect,  stimulants  should  be  used,  mild  or  strong, 
as  the"  circumstances  require.  If  excessive,  ice  may  be  apjjlied  to  the  head,  and 
cold  water  allowed.  If  there  is  a  tendencj^  to  cerebral  congestion,  leeches  and  cups 
should  be  employed.  To  restore  the  urinary  secretion,  mild  diuretics,  such  as 
seltzer  waters,  citric  acid,  or  citrate  of  potassa,  are  indicated.  If  necessary, 
warmth  may  be  applied  to  the  loins  and  frictions  made  witli  ungt.  digitalis,  the 
oil  of  juniper,  or  turpentine.     A  free  use  of  cold  water  is  also  allowable. 

If  the  diari'hoea  continues  during  reaction,  astringents,  such  as  tannin,  extract 
of  calumba  and  extract  of  rhatany,  should  be  administered.  The  same  remedies, 
are  indicated  if  diarrhoea  is  present  in  consecutive  fever.  Vomiting  and  singultus, 
are  treated  by  sinapisms  to  the  epigastrium.  So  long  as  the  period  of  reaction 
continues,  the  patient  must  remain  in  bed  and  confine  himself  to  a  diet  of  soups 
alone. 

For  the  diarrhoea  and  vomiting  which  sometimes  continue  during  convales- 

in  the  preceding  chapter,  cannot  be  called  in  question.  Drasche  condemned  it 
without  having  extensively  employed  it,  and  we  must,  therefore,  take  exception 
to  his  statement,  according-  to  which  it  should  be  classed  witli  the  useless  drugs. 

'  The  castor-oil  treatment  of  cholera  has  been  extensivel}^  tried  and  is  now  gen- 
erally abandoned  as  unworthj^  of  confidence.  Jolinson's  idea  of  eliminating  the 
specific  poison  from  the  alimentary  canal  by  the  promotion  of  purging  was  doubt- 
less ingenious.  But  apart  from  the  practical  failure  of  his  methods,  we  have,  in 
the  light  of  our  present  knowledge  concerning  cholera,  no  reason  to  believe  tliat 
we  can  rid  the  system  of  tliis  poison  by  castor-oil  or  any  similarly  acting  drug. 

-  The  language  is  borrowed  from  Burrall. 

9ri 


386  ASIATIC  CHOLERA. 

cence,  nux  vomica  is  a  suitable  remech-.  So  long  as  there  is  anj'  indication  that 
the  digestive  organs  are  still  sutlering,  the  diet  must  consist  principally  of  nutri- 
tious soups. 

From  this  brief  resume  of  Drasche's  views  it  Avill  be  seen  that  the  ra- 
tional treatment  of  cholera,  as  we  understand  it  to-day,  is  in  many  respects 
quite  similar  to  what  it  was  25  years  ago. 

The  plan  of  treatment  as  mapped  out  by  Niemeyer,  Lebert,  Eichhorst, 
Kuessner  and  Pott '  and  other  representative  German  writers,  resembles  in 
all  its  essential  points  the  method  of  Drasche,  just  described. 

In  the  premonitory  diarrhoea  of  cholera  Lebert  claims  to  have  obtained 
excellent  results  from  the  use  of  the  following  pills: 

3.  Argenti  nitratis  ....  gr.  ix. 

■    Solve  in  aqua?  destillatae  .         .  q.  s.,  et  adde. 

Extracti  opii  .....  gr.  ivss. 

Pulveris  altlia?         ....  gr.  xxij. 

Extracti  gentiana?  .         .         .         .  q.  s. 

Misce,  et  fiat  massa  in  pilulas  xxx.,  dividenda. 

Let  one  of  these  pills, be  given  two  or  three  times  a  day  in  cases  of  slight 
diarrhoea,  and  two  pills  three  times  a  day  in  the  more  severe  and  obstina'ie 
cases. 

Numerous  authors  of  standard  text-books  on  medicine,  and  many 
representative  English,  French,  Italian  and  Spanish  writers,  while  they 
advise  treatment  that  differs  considerably  in  its  details,  nevertheless  adhere 
to  the  same  general  plan  of  management  that  has  previously  been  described. 

We  must  now  turn  to  the  specific  recommendations  of  some  of  the  most 
recent  writers.  And  we  will  begin  with  an  Italian  author,  Semmola,^  who 
claims  to  have  employed  with  gratifying  results,  and  naturally  commends 
as  worthy  of  extended  trial,  a  plan  of  procedure  upon  Avhich  he  has  be- 
stowed the  title  of  "  physiological  treatment."  By  this  he  means  the  em- 
ployment of  measures  suitable  for  increasing  the  jjower  of  resistance  of 
the  system  against  the  invasion  of  the  choleraic  poison,  without,  however, 
troubling  the  organism  with  powerful  pharmaceutical  preparations.  The 
principal  points  in  this  mode  of  treatment  are: 

1.  Absolute  repose  of  the  organs  attacked — that  is  of  the  gastro-intestinal 
tract — by  a  strict  fast  maintained  from  the  very  first  appearance  of  diarrhcea. 
This  fast  must  be  enforced  at  once  upon  the  appearance  of  a  liquid  stool, 
without  waiting  to  see  whether  the  diarrhoea  is  merely  accidental  or  is 
premonitory  of  cholera.  The  taking  of  even  a  single  cup  of  l)eef-tea  may 
suffice  to  develop  a  grave  attack  of  cholera.  The  author  thinks  the  ne- 
cessity of  this  absolute  fast  is  too  little  insisted  ujion,  for  he  regards  it,  he 
says,  as  the  sheet-anchor  of  safety.  The  same  complete  fast  is  to  be 
maintained  during  the  period  of  reaction  until  at  least  24  hours  have 
elapsed  since  the  last  liquid  stool.  The  author  says  that  he  has  seen  a 
return  of  all  the  grave  symptoms  of  the  algid  stage  following  the  too  early 
administration  of  a  few  spoonfuls  of  beef -tea. 

2.  Arousing  the  physiological  powers  by  measures  therapeutical  indeed, 
but  bordering  on  the  physiological.  This  consists  in  the  application  of 
heat  in  the  form  of  hot  baths  of  a  temperature  of  100°  to  104°  F.  repeated 
as  necessar}'.  Hot  baths  have  been  given  often  enough  in  cholera,  but 
they  have  not  been  given  at  the  proper  time.     The  suitable  time  to  em- 

'  Die  acuten  Infections  Krankheiten,  Braunschweig,  1882. 
-  Bulletin  General  de  Therai)eutique,  December  15,  1884. 


SEMMOLA'S  PHYSIOLOGICAL  TREATMENT.  387 

ploy  them  is  in  the  beginning  of  the  disease,  before  the  algid  stage  has 
set  in.  For  the  object  is  not  to  warm  the  chilled  cutaneous  surface,  as 
"was  formerly  supposed,  but  to  maintain  the  normal  physiological  relations 
between  the  cutaneous  surface  and  the  gastro-intestinal  mucous  membrane. 
The  hot  bath,  of  100"  to  104°,  excites  the  very  rich  peripheral  nervous 
plexuses,  and  then  by  reflex  action  the  nervous  centers  of  the  circulation. 
The  hot  bath  favors  also  the  elimination  with  the  perspiration  of  the  toxic 
principles,  which  are  the  cause  of  the  nervous  and  other  symptoms  charac- 
teristic of  the  algid  stage.  The  bath  should  be  repeated  every  hour  or 
two.  and  in  the  intervals  the  patient  should  be  kept  covered  with  woolen 
clothes  and  should  take  some  warm  aromatic  and  alcoholic  drink.  Sem- 
mola  advises  that  the  baths  should  be  begun  as  soon  as  the  patient,  even 
though  the  diarrhoea  be  slight,  feels  any  epigastric  uneasiness  whether  vom- 
iting have  occurred  or  not.  The  uneasiness  or  distress  is  the  precursory  sig- 
nal of  a  terrible  struggle,  and  no  time  should  be  lost  in  putting  the  patient 
into  a  hot  bath  for  ten  or  fifteen  minutes.  In  other  cases  also,  when  there 
is  simple  diarrhoea  without  any  epigastric  discomfort,  if  the  diarrhoea  is 
not  speedily  arrested  by  the  ordinary  treatment,  fasting,  rest,  opium,  etc., 
the  writer  counsels  a  recourse  to  the  hot  bath.  He  says  he  has  seen  hun- 
dreds of  cases  of  diarrhoea  rebellious  to  ordinary  remedies,  which  would 
probal)ly  have  eventually  passed  into  actual  cholera,  but  which  yielded  at 
■once  after  one  or  two  hot  baths. 

3.  The  administration  of  small  doses  of  opium  to  blunt  the  nervous 
centers  and  thus  render  them  less  susceptil^le  to  the  influence  of  the  toxic 
agent.  This  is  independent  of  the  favorable  influence  which  opium  may 
■exert  upon  the  intestinal  secretion.  The  stupefying  action  of  the  drug 
upon  the  nervous  centers  increases  their  power  of  resistance  to  the  cholera 
poison,  and  thus  really  constitutes  part  of  the  physiological  treatment  of 
the  disease. 

Some  of  Semmola's  suggestions  are  worthy  of  being  heeded.  The  ad- 
yantage  of  obtaining  as  much  rest  as  possible  for  the  digestive  tract  is  self- 
evident.  Nevertheless  we  cannot  enforce  a  prolonged  regime  of  fasting 
in  every  case  menaced  with  an  attack  of  cholera.  The  weak  would,  in 
place  of  being  benefited  thereby,  sulfer  positive  injury.  Nor  does  the  in- 
discriminate employment  of  warm  baths  strike  us  as  a  measure  free  from 
possible  harm.  It  should  be  restricted  to  those  cases,  in  which  the  physi- 
cian feels  satisfied  that  no  mischief  can  be  wrought,  rather  than  extended 
to  all,  in  which  a  possible  benefit  might  be  obtained. 

Professor  Hayem, '  the  well-known  ha?matologist,  has  recently  published 
in  extenso  his  views  on  the  treatment  of  cholera.  The  following  brief 
summary  embodies  the  points  on  which  he  appears  to  lay  the  most  stress. 
He  first  draws  attention  to  a  circumstance,  which  all  competent  writers 
are  agreed  upon,  namely,  how  important  it  is  to  remember  that,  in  a  very 
large  proportion  of  cases,  cholera  begins  with  gastro-intestinal  troubles, 
and  that  if  these  are  arrested  in  their  incipiency,  a  grave  attack  may  pos- 
sibly be  prevented.  It  is,  therefore,  necessary  during  an  epidemic  to  at- 
tend at  once  to  all  intestinal  or  digestive  disturbances,  and  esjiecially  to 
diarrhcea.  If  there  is  indigestion  or  if  there  are  signs  of  an  overloaded 
stomach,  ipecac  may  be  given  in  a  dose  of  20  to  30  grains.  It  may  even 
suffice,  in  certain  cases,  to  produce  emesis  by  tickling  the  fauces  with  a 
feather  or  by  causing  the  patient  to  drink  large  quantities  of  warm  water, 

'  Bulletin  General  de  Therapeutique,  November  30,  1884,  and  Ti-aitement  du 
Cholera,  Paris,  G.  Masson,  1885. 


ogg  ASIATIC  CHOLERA. 

In  the  treatment  of  the  premonitory  diarrhoea,  opinm  may  be  given  by 
the  mouth,  or  in  combination  with  an  astringent  by  the  rectum.  Sub- 
nitrate  of  bismuth  has  often  been  given  with  advantage  in  doses  of  3  to  3 
drachms  during  the  twenty-four  hours.  Hayem  states  that  he  has  also 
employed  tlie  black  sulphide  of  mercury  so  highly  recommended  by 
Cadet  with  success.  He  gave  it  in  doses  of  15  grains  every  hour  until 
twelve  doses  had  been  taken,  and  found  that  it  speedily  checked  the  diar- 
rhoea. He  recommends  also  the  salicylate  of  bismuth,  as  suggested  by 
Vulpian,  asserting  that  it  is  decomposed  in  the  intestinal  canal  forming 
oxide  of  bismuth  and  salicylic  acid,  acting  thus  at  the  same  time  as  an 
astringent  and  an  anti-zymotic. 

After  the  disease  has  become  fully  established,  when  the  intestines  are 
filled  Avith  fluid,  the  remedial  agents  which  may  be  given  are  with  difficulty 
absorbed.  When  the  attack  begins  suddenly  without  ])rodromic  symptoms, 
or  when  these  early  symptoms  have  not  been  treated,  Hayem  still  advo- 
cates the  employment  of  ipecac,  and  says  that  it  often  is  effectual  in  arrest- 
ing the  vomiting.  Purgatives,  which  have  been  so  often  used,  are  rather 
harmful  than  otherwise.  Opium  may  also  be  given  at  the  beginning  of  this 
stage,  but  its  exhibition  should  not  be  long  continued,  as  the  drug  may 
accumulate  in  the  intestines,  and  then  be  rapidly  absorbed  in  massive  dose 
when  reaction  sets  in.  But  salicylate  of  bismuth  is  of  especial  value  in 
this  stage,  and  may  be  given  to  the  amount  of  2|-  drachms  a  day  in  doses  of 
15  grains  each.  The  black  sulphide  of  mercury  appears  to  be  of  little 
efficacy  at  this  period.  Often,  hoAvever,  the  administration  of  any  remedy 
is  interfered  with  by  the  continual  vomiting,  and  recourse  must  then  l)e  had 
to  hypodermic  medication.  The  muriate  of  morphine  may  be  given  in  this 
Avay'  in  doses  of  one-seventh  of  a  grain,  and  is  often  of  great  service  in  con- 
trolling the  vomiting,  diarrhoea,  and  nervous  symptoms.  These  hypo- 
dermic injections  may  be  employed  until  the  algid  stage  has  become  es- 
tablished, after  which  time  they  are  useless,  as  absorption  then  ceases. 

A  mustard  plaster  or  a  small  blister  over  the  epigastrium  may  be  of 
service  to  control  vomiting.  In  the  algid  stage  Hayem  strongly  urges  the 
emplovment  of  intravenous  saline  injections.  O^ving  to  the  excessive 
transudation  of  serum  into  the  intestines,  the  blood  is  greatly  reduced  in 
volume;  it  becomes  inspissated,  circulates  but  slowly  in  the  vessels,  and 
carbonic  acid  accumulates  in  it  to  such  an  extent  that  it  may  even  become 
acid  in  reaction.  The  transfusion  of  blood,  as  recommended  by  Dieff en- 
bach,  is  irrational,  since  it  is  only  the  fluid  elements  that  demand  renewal. 
Hayem  asserts  that  there  is  practically  no  danger  in  increasing  the  bulk  of 
the  circulating  fluid  by  saline  injections,  since  he  has  shown  by  experi- 
ments on  animals  that  a  quantity  of  water  equal  to  the  entire  mass  of  the 
blood  may  be  added  without  causing  any  serious  inconvenience.  These 
experiments  were  practiced  on  healthy  animals  Avhose  vascular  system  was 
alreadv  normally  full. 

The  simplest  fluid  for  these  injections  is  a  solution  of  5  parts  per 
thousand  of  chloride  of  sodium  in  Avater.  To  this  may  be  added  one 
part  of  carbonate  of  soda  Avhich  is  indicated  by  reason  of  the  in- 
creased alkalinity  of  the  blood.  Tbe  solution  is  to  be  previously  Avarmed 
and  passed  throiigh  three  thicknesses  of  good  filter  paper,  or  better  yet 
through  a  heated  porcelain  filter  such  as  is  used  in  sterilizing  culture 
fluids.  The  injection  is  to  be  made  in  the  same  way  as  in  the  transfusion 
of  blood,  and  is  the  more  easily  accomplished  since  there  is  no  litemorrhage. 
One  of  the  veins  at  the  elboAv  or  the  saphenous  A'ein  is  to  be  chosen.     A 


INTRAVENOUS   INJECTIONS.  3g9 

transverse  incision  having  been  made  through  the  integument,  the  subcu- 
taneous celhilar  tissue  is  seized  with  the  forceps  and  divided  by  bhmt 
pointed  scissors  until  the  vein  is  exposed  into  which  the  canula  is  inserted 
by  a  single  thrust.  Another  solution  which  Hayem  regards  with  great 
favor  is  the  preceding  one,  with  the  addition  of  "25  parts  per  thousand  of 
sulphate  of  soda,  which  has  Ijeen  found  to  l)e  an  excellent  preservative  of 
the  integrity  of  the  red  globules.  It  has  been  shown  that  sulphate  of  soda 
introduced  directly  into  the  circulation  does  not  act  as  a  laxative,  but 
rather  causes  constipation,  and  Hayem  suggests  that  not  only  may  it  arrest 
any  further  transudation  of  fluid  into  the  intestines,  but  possibly  it  may 
even  promote  the  reabsorption  of  that  already  escaped  from  the"  vessels". 
For  the  sake  of  convenient  reference  the  formula  of  this  solution  is  here 
given : 

Carbonate  of  Soda      ......         I'part. 

Chloride  of  Sodium    ......         5  parts. 

Sulphate  of  Soda 35      '• 

Water 1000      " 

If  the  amount  of  fluid  to  be  injected  is  more  than  a  litre  (If  pints)  it 
would  perhaps  be  prudent  to  reduce  somewhat  the  proportion  of  the  sul- 
plmte  of  soda.  M.  Hayem  estimates  the  amount  of  injection  needed  by 
the  proportion  of  red  globules  or  the  dosage  of  hemoglobine  in  the  blood. 
Thus  if  the  proportion  of  red  corpuscles  is  increased  to  7,000,000  or  8,000,000 
per  cubic  millimetre,  instead  of  4,000,000  or  5,000,000  which  is  the  nor- 
mal quantity,  about  two  litres  (3^  pints)  must  be  injected,  since  the  entire 
mass  of  blood  in  the  healthy  adult  is  estimated  at  about  5  litres  (9  pints). 

In  certain  cases,  owing  to  an  abundance  of  cellular  tissue  about  the 
veins  and  to  the  collapse  of  the  vessels  from  the  disturbed  circulation,  it 
may  be  impossible  to  practice  these  intravenous  injections.  In  such  cases 
Hayem  would  not  abandon  the  attempt  to  restore  the  normal  fluidity  of 
the  blood,  but  would  throw  the  injection  into  the  cavity  of  the  peritoneum. 
The  solution,  whether  thrown  into  the  veins  or  into  the  peritoneum, 
should  not  be  warmed  above  the  normal  temperature  of  the  body. 

The  feebleness  of  the  cardiac  pulsations  may  contribute  to  the  produc- 
tion of  collapse  in  the  algid  stage,  and  is  to  be  met  by  the  employment  of 
external  heat  and  diffusible  stimulants.  The  painfiil  cramps  may  be  re- 
lieved by  passive  movements,  dry  frictions,  massage,  or  frictions  with 
chloroform  liniment.  The  nervous  symptoms,  agitation,  cardialgia  and 
depression,  may  be  effectually  quieted  by  cold  affusions. 

The  intravenous  injection  of  fluid,  practiced  with  the  idea  of  making 
lip  for  its  loss  by  intestinal  transudation,  is  not  a  new  idea.  But  neither 
the  older  nor  the  most  recent  trials  were  followed  by  results  that  Avere 
sufficiently  lasting  to  encourage  physicians  in  the  universal  adoption  of 
such  a  procedure.  There  is  little  doubt  that  a  failing  heart  may  be  stimu- 
lated to  renewed  activity  by  being  supplied  with  fresh  fluid.  But  when  the 
latter  reaches  the  intestine  it  will  certainly  escape  from  vessels  that  are 
unable  to  retain  even  the  natural  serum  of  the  blood.  Practiced  with  the 
idea  of  temporary  cardiac  stimulation,  the  intravenous  injection  of  fluid 
may  take  its  place  by  the  side  of  other  legitimate  procedures.  But  under- 
taken for  the  purpose  of  curing  the  patient,  by  maintaining  the  fluidity 
of  his  blood,  even  Hayem's  warm  recommendations  will  fail  to  obtain  for 
it  universal  professional  sanction. 

Dr.  Lereboullet '  in  reviewing  all  the  recent  suggestions  regarding  the 

'  Dii  Traiteuient  du  Cholera,  in  Bulletin  General  de  Therapeutique,  September 
30,  and  October  15,  1884. 


390  ASIATIC  CHOLERA. 

therapy  of  cholera  conchides  that  the  following  measures  will  meet  all 
pos&sible  indications.  Premonitory  diarrhcea  must  be  combated  by  opium 
and  anti-spasmodics,  as  well  as  iodoform  in  the  shape  of  pills.  He  believes 
that  the  multiplication  of  the  specific  microbes  may  thus  be  held  in  check. 

In  the  algid  stage  of  an  attack,  the  inhalation  of  nitrite  of  amyl,  in- 
jections of  ether,  practised  coup  siir  coup  until  a  decided  effect  is  observed, 
are  necessary.  Hydro-therapy  and  inhalations  of  oxygen  are  likewise  to 
be  recommended.  If  absorption  appears  to  have  come  to  a  standstill,  he 
urges  the  employment  of  copious  intravenous  injections,  frequently  re- 
peated. Finally  he  points  out  that  the  practitioner  can  only  hope  to  treat 
his  patients  with  success,  if  he  is  able  to  visit  them  repeatedly  and  at  short 
intervals,  so  that  all  the  varying  indications  may  be  immediately  acted 
upon. 

The  presence  of  soda  ni  the  intestinal  contents  and  its  diminution  in. 
the  blood  are  due,  Tardani  thinks,  to  endosmosis. '  The  indication  is, 
therefore,  to  arrest  this  process,  and  this  is  to  be  accomplished  by  the  in- 
troduction of  a  small  amount  of  sulphureted  hydrogen  together  Avith  an 
acid  fluid  into  the  intestine.  The  author  injects  into  the  bowel  six  or 
seven  grains  of  sulphide  of  sodium  dissolved  in  thirty  times  its  Aveight  of 
water,  and  follows  this  at  once  by  another  injection  of  two  ounces  of  Avater 
acidulated  Avith  sulphuric  acid. 

In  a  little  pamphlet  from  the  pen  of  Dr.  Hanhart '  a  "  regime  of  thirst " 
is  recommended  as  a  prophylactic  during  the  preA"alence  of  epidemic  cholera. 
The  author  meajis  thereby  a  considerable  reduction  in  the  amount  of  fluid 
ordinarily  imbibed.  Should  an  attack  nevertheless  occur,  the  patient  must 
refrain  altogether  from  taking  liquids.  Frictions  ahvays  calm  the  restless- 
ness.    Nitrogenous  and  carbonaceous  food  is  alone  admissible. 

Accordingly  the  patient  must  eat  tender  meat,  preferably  prepared  Avith 
vinegar  or  lemon-juice.  Also  oil,  rum,  brandy,  and  sugar.  Chocolate  also 
ansAvers  the  same  purpose.  In  fact,  whatever  dries  the  bod}^  is  useful. 
This  author  forgets  to  publish  the  results  he  has  obtained  AA'ith  this  extra- 
ordinary and  unique  plan  of  "  fighting  cholera."  It  is  quite  obvious,  hoAv- 
ever,  that  his  method  of  treatment  has  nothing  in  its  favor.  It  is  mentioned 
only  in  order  to  be  condemned  as  utterly  irrational. 

M.  Burq,  the  tireless  champion  of  the  therapeutic  efficacy  of  metallo- 
therap}-,  published  a  little  brochure  ^  shortly  before  his  death,  applying 
these  principles  to  the  treatment  of  cholera.  In  this  he  urged  as  a  certain 
means  of  prophylaxis  the  charging  of  the  system  with  copper.  Each 
person  Avas  advised  to  take,  according  to  his  age,  from  one  to  six  pills 
containing  each  \  grain  of  binoxide  of  copper.  Among  the  immediate 
followers  of  Burq  the  copper  treatment  Avas  regarded  Avith  much  favor. 
But  the  results  were,  as  might  have  been  foreseen,  indifferent  or  unfavor- 
able.    Further  trials  of  this  medicament  are  not  called  for, 

Dr,  Huguet'  maintains  that  all  that  is  necessary  is  to  remove  the 
morbific  agent  of  the  disease  from  the  economy  as  speedily  as  possible  by 
the  natural  channels.  To  accomplish  this  end  he  stimulates  all  the  excre- 
tory functions  of  the  lungs,  the  skin,  the  kidneys,  the  intestines  and  the 

'  Sohition  du  Probleme  du  Cholera  Morbus,  per  Gaetano  Tardani,  3d  edition, 
Paris,  1884. 

-  La  lutte  centre  le  Cholera,  par  H.  Hanhart.  Paris,  1884 

"  Du  CuiATe  centre  le  Cliolera  et  la  Fievre  Typlioide.     Paris,  1884. 

•*  Extinction  du  Cholera.  Guerison  en  quelques  Heures,  oar  la  Metliode  naturelle. 
Paris,  1884. 


ENTEROCLYSIS  AND   HYPODERMOCLYSIS.  39 1 

stomach,  giving  if  need  be  remedies  to  excite  those  various  organs  to  in- 
creased action.  This,  it  will  be  observed  is  an  eliminative  method  practiced 
on  a  much  larger  scale  than  Johnson's  castor-oil  treatment.  It  does  not 
recommend  itself  for  further  trial,  being  based  on  erroneous  assumptions. 
Apart  from  this  the  method  is  fraught  with  positive  danger,  on  account 
of  the  weakening  and  depressing  effect  it  necessarily  exerts  upon  patients 
subjected  to  such  ordeals. 

In  a  number  of  publications  issued  during  the  latter  part  of  the  year 
1884,  Professor  Arnaldo  Cantani '  relates  the  mode  of  treatment  advocated 
and  employed  by  him  during  the  recent  epidemic  in  Italy.  Accepting 
the  bacillar  theory  of  the  disease,  he  cautions  against  the  employment  of 
alkalies  such  as  bismuth,  magnesia  or  chalk,  in  the  treatment  of  the  pre- 
monitory diarrhoea,  and  advises  per  contra  the  use  of  acids,  especially 
hydrochloric  or  lactic  in  the  form  of  lemonade.  In  addition  a  little 
laudanum  may  be  given  in  a  hot  aromatic  infusion.  The  patient  should 
go  to  bed  at  once  and  should  be  warmly  covered  so  as  to  promote  diaphoresis. 
But  he  urges  especially  the  use  of  rectal  injections,  thrown  as  high  up 
into  the  bowel  as  possible.  His  formula  for  these  injections  is  the  fol- 
lowing: 

Deodorized  tincture  of  opium,  .         .         .         30  to  50  drops. 

Tannic  acid,     .         .         .         .         .         .         45  to  90  grains. 

Gum  arable,     .         .         .         .         .         .         1  to  1|  ounces. 

Infusion  of  chamomile,     .         .         .         .         3|  pints. 

In  regard  to  the  use  of  this  injection  in  the  beginning  of  the  disease, 
Cantani  says  that  he  is  persuaded  from  practical  experience  that,  employed 
in  time,  it  will  almost  always  arrest  the  rice-water  discharges  and  cut 
short  the  disease. 

In  the  few  cases  in  which  this  abortive  treatment  fails,  or  when  the 
patient  is  not  seen  until  the  algid  stage  has  already  set  in,  recourse  must 
be  had  to  subcutaneous  injections  (hypodermoclysis)  of  a  saline  solution 
containing  three  parts  of  carbonate  of  soda  and  four  parts  of  chloride  of 
sodium  to  1,000  parts  of  distilled  water  of  a  temperature  equal  to,  or  a 
little  above,  that  of  the  normal  body.  These  injections  are  to  be  made  into 
the  subcutaneous  tissues  on  each  side  of  the  body,  in  the  subclavicular  and 
in  the  ileocostal  regions,  and  are  to  be  repeated  as  long  as  the  loss  of  fluid 
through  the  intestines  continues. 

A  similar  mode  of  treatment  has  been  advocated  by  Professor  Samuel 
of  Konigsberg,  in  a  recent  brochure.'  He  uses,  however,  six  parts  of  chlo- 
ride of  sodium  and  only  one  of  carbonate  of  soda  to  1,000  of  water,  a  solu- 
tion which  Cantani  does  not  consider  sufficiently  alkaline  to  overcome  the 
tendency  to  acidity  of  the  blood.  Cantani  seems  to  have  established  his 
claims  to  priority  in  the  use  of  this  method,  since  he  advocated  it  in  an 
article  in  the  journal  Morgagni  in  1867,  and  even  before  that  time  in  his 
notes  added  to  an  Italian  translation  of  Niemeyer  in  18G5. 

In  this  connection  mention  may  also  be  made  of  the  fact  that  Surgeon- 
Major  E.  T.  Kellat,^  attempted  to  arrest  the  disease  by  injecting  distilled 

'  L'  Enteroclesi  tannica  calda  come  cura  abortiva  del  Cholera,  etc.  Naples,  1884. 
II  Cholera:  Lettera  del  Pi'of.  Arnaldo  Cantani;  Milano,  1884.  Istruzioni 
Popolari  concernenti  il  Cholera  Asiatico:  Napoli,  1884.  La  Cura  del  Cholera 
mediante  I'lpodermoclisi  e  TEnteroclisi,  3d  Edition,  Naples,  1884. 

^Die  subcutane  Infusion  als  Behandlungsmethode  der  Cholera,  Stuttgart, 
1883. 

=*  Aitken's  Practice  of  Medicine,  London,  1880,  vol.  i.,  p.  743. 


392  ASIATIC  CHOLERA. 

water,  at  a  temperature  of  99°  F.,  liypodermically  or  into  the  cavity  of 
the  peritoneum.  The  object  he  had  in  view  was  the  production  of  an 
artificial  anasarca  and  ascites  that  miglit  supply  the  fluid  drained  away 
through  tlie  intestines. 

But  to  return  to  the  writings  of  Cantani.  He  holds  that  a  second 
indication  in  the  treatment  of  cholera  is  the  disinfection  of  the  intestinal 
contents.  He  proposes  to  accomplish  this  by  an  injection  thrown  far  .up 
into  the  bowel  of  the  following  solution: 

Crystallized  Carbolic  Acid,         .         .         .         8  to  30  grains. 

Alcohol,  sufficient  to  dissolve  it. 

Distilled  Avater,  ......         3|  pints. 

Even  larger  amounts  of  carbolic  acid  may  be  used  during  the  algid  stage, 
when  intestinal  absorption  is  suspended,  but  caution  is  to  be  observed  not 
to  continue  the  use  of  such  large  doses  of  the  acid  after  reaction  sets  in 
and  resorption  is  established.  He  adds  that,  since  all  acids  are  destructive 
to  the  cholera  bacillus,  use  may  be  made  of  those  which  are  not  poisonous, 
such  as  hydi'ochloric  (a  drachm  to  the  pint),  lactic  (one  to  four  drachms 
to  the  pint),  or  tannic  (^  drachm  to  the  pint).  It  is  important  that  these 
injections  should  be  warmed  up  to  100*^  or  104°  F.  At  the  same  time  the 
patient  may  sip  from  time  to  time  a  little  muriatic  or  lactic  acid  lemonade. 

Dr.  Duboue, '  of  Pan,  advises  the  use  of  pure  tannin  in  four-grain  doses 
taken  as  a  prophylactic  against  the  disease  during  cholera  times.  The 
drug  should  be  given  twice  a  day  before  the  two  principal  meals.  When 
premonitory  diarrhoea  occurs,  the  dose  must  be  tripled  or  quadrupled. 
During  the  attack  he  recommends  rectal  injections  of  from  2  to  6  quarts 
of  water,  containing  15  grains  of  tannin  to  the  quart,  a  method  which  will 
be  seen  to  resemble  the  tannic  acid  enteroclysms  just  described. 

Cantani's  tannic  acid  treatment  has  been  tried  by  a  number  of  Italian 
physicians,  and  some  of  them  appear  to  have  obtained  satisfactory  results. 
Thus  Dr.  Vitone  lias  published,"  the  results  of  his  method  of  treatment  at 
the  Cholera  Orphanage  at  S.  Antonio  a  Tarsia.  The  children  admitted 
to  this  institution  came  from  the  most  infected  parts  of  the  city,  and 
had  lost  one  or  both  parents  from  cholera. 

The  writer  asserts  that  in  a  large  number  of  cases  the  cholera  Avas 
promptly  arrested  by  tannic  acid  clysters. 

Dr.  E.  Villain  also  states  that  lie  has  injected  per  rectum  as  much  as 
half  an  ounce  of  tannic  acid  in  two  quarts  of  warm  Avater,  Avith  invariably 
good  results.  The  modus  opera7idi  of  the  treatment  is  attributed  to  the 
astringent  power  of  tannic  acid,  and  to  its  sterilizing  the  comma-bacilli, 
Avhicli  need  an  alkaline  solution  for  their  development.  The  London 
Lancet  of  February  21.  1885,  makes  the  following  comment  upon  these 
publications:  "Without  entering  into  this  theoretical  disquisition,  the 
clinical  results  appear  to  afford  striking  evidence  of  the  efficacy  of  Avarm 
tannic  acid  clysters  in  the  treatment  of  cholera." 

But  in  spite  of  such  favorable  opinions  regarding  this  method,  it  does 
not  recommend  itself  to  the  practitioner  for  universal  adoption  in  the 
treatment  of  tne  oisease.  On  the  other  hand,  in  seA'ere  attacks  a  tentative 
trial  may  be  made  of  it,  as  it  has  in  its  favor  the  fact  that,  Avhen  not  too 
vigorously  pushed,  it  is  at  least  free  from  too  great  annoyance  and  danger. 
One  practical  point  must  not  be  forgotten,  if  recourse  be  had  to  large 

1  Bulletin  General  de  Thempeutique,  October  30,  1881 
-  II  Morgag'ni,  JanuarA-,  1885. 


SPECIAL   METHODS   OF   TREATMENT.  393 

enemata,  namely,  the  elevation  of  the  hips  above  the  level  of  the  trunk, 
and  the  gradual  introduction  of  the  warm  fluid. 

In  the  successful  treatment  of  cholera  the  principal  indications,  ac- 
cording to  Dr.  F.  Jousseaume, '  are  to  arrest  the  vomiting  and  diarrhoea  and 
reestablish  the  urinary  secretion.  To  this  end  he  gives  a  powder  of  5 
grains  each  of  chalk  and  bicarbonate  of  potash  dissolved  in  a  little  water, 
and  immediately  afterward  half  a  glassful  of  water  containing  about  20 
minims  of  nitric  acid  to  the  pint.  Carbonic  acid  is  thus  set  free  in  the 
stomach,  which  is  the  most  eft' ectual  means  of  controlling  vomiting.  Xitric 
acid  is  an  excellent  remedy  for  diarrhoea  and  nitrate  of  jDotash  is  one  of 
the  best  diuretics  which  we  possess. 

Among  the  extraordinary  recommendations  regarding  treatment,  we 
may  mention  those  of  Dr.  F.  X.  Poznanski.  This  Avriter  was  sent  by  the 
Eussian  Government  to  study  the  cholera  in  the  infected  districts.  He 
published  in  Naples'  a  brochure  embodying  the  method  employed  by  him 
m  several  epidemics  with,  he  claims,  excellent  results.  It  is  necessary,  he 
says,  to  prevent  stagnation  of  the  blood  in  the  vessels,  and  this  is  to  be 
done  by  increasing  the  activity  of  the  respiration  and  circulation.  With  this 
object  in  view  he  employs  a  snuff  of  veratrum  album  to  cause  sneezing. 
This  act  accelerates  the  circulation  and  expels  a  quantity  of  carbonic  acid 
from  the  pulmonary  atmosphere. 

In  the  second  place  he  advocates  a  rapid  but  moderate  venesec- 
tion. Bleeding,  he  maintains,  diminishes  the  resistance  which  the 
blood  offers  to  the  action  of  the  heart.  That  this  practice  has  fallen 
into  desuetude  in  the  treatment  of  cholera  is  due  rather,  the  author 
thinks,  to  ignorance  of  its  efficacy  than  to  its  abuse  in  former  times.  Lastly 
he  employs  dilute  hydrocyanic  acid  (2  per  cent,  strength)  in  doses  of  5  to  20 
drops,  which  he  says  strengthens  the  pulse  and  increases  its  rapidity  by 
several  beats  in  the  minute;  the  respirations  are  also  increased  somewhat 
in  frequency  and  depth.  Since  the  action  of  the  acid  is  very  evanescent, 
it  must  be  given  at  repeated  intervals  of  ten  or  fifteen  minutes.  He  also 
throws  a  spray  of  some  alkaline  solution  into  the  buccal  cavity  with  the 
idea  of  neutralizing  the  excess  of  carbonic  acid. 

M.  Eodriguez  Merino  of  Madrid,  a  telegrapher,  has  given  to  the 
world  his  peculiar  views  in  a  little  pamplilet. '  Ozone,  he  says,  is  one  of 
the  best  of  disinfectants,  solely  because  it  creates  electricity — and  indeed 
all  disinfectants  owe  their  properties  to  the  fact  that  they  produce 
electricity.  Therefore,  why  not  give  electricity  in  the  first  place  ?  Ac- 
cordingly the  author  suggests  that  cholera  patients  be  put  together  hand 
in  hand  and  then  be  charged  with  electricity  by  means  of  a  Euhmkorff 
coil.  The  strength  of  the  current  is  to  be  regulated  according  to  the 
needs  of  each  case  or  batch  of  cases.  This  procedure  is  also  recommended 
as  a  prophylactic. 

The  extensive  employment  of  ozone  as  a  disinfectant  rather  than  a 
curative  agent,  is  advocated  by  Dr.  Ouimus.  *  He  says  during  the  preva- 
lence of  cholera,  there  is  always  an  appreciable  diminution  of  atmospheric 
ozone.  This  deficiency  he  seeks  to  supply  by  placing  in  hospital  wards, 
private  dwellings,  etc.,  dynamo-electric  machines  that  generate  as  much 

^  Du  Cholera.    Traitement  Nouveau,  Guerison.  Paris,  1884. 
^  Diagnosi  profillaticae  terapeutica  del  colera  epidemico.     Per  Fr.  X.  Poznan- 
ski.    Napoli,  1884. 

3  La  Electricidad  y  el  Colera.     Madrid,  1884. 
*  Ozone  et  Cholera.     Paris,  1884. 


394 


ASIATIC  CHOLERA. 


ozone  as  may  be  needed  for  ^^articnlar  purposes.  He  says  that  it  purifies 
the  air,  and  acts  as  a  stimiilant  upon  patients.  He  does  not  claim  that  it 
cures  cholera,  any  more  than  the  absence  of  ozone  from  the  atmosphere 
gives  rise  to  the  disease. 

It  would  be  unprofitable  and  tiresome  to  examine  further  the  various 
suggestions  regarding  the  treatment  of  cholera  that  have  come  to  light 
within  the  past  two  years.  All  the  most  important  writings  of  different 
authors  have  been  alluded  to. 

In  reviewing  the  entire  subject,  candor  compels  the  admission  that 
the  real  additions  to  our  knoAvledge  concerning  the  rational  treatment  of 
the  disease  have  amounted  to  little  or  nothing.  There  is  no  doubt  that 
the  list  of  useless  medicaments  and  measures  has  been  still  further  ex- 
tended, and  so  far  we  have  to  record  at  least  a  negative  gain. 

But  if  Koch's  doctrine  has  thus  given  no  direct  stimulus  to  the  practical 
management  of  the  disease,  we  cannot  ignore  the  fact  that  in  accepting 
it,  we  deal  more  intelligently  with  our  patients  than  was  possible  before. 
Still,  the  chief  interest  and  importance  of  future  cholera  research  Avill 
undoubtedly  center  around  the  subject  of  effectual  scientific  prophylaxis. 

Protective  Inoculation  against  Cholera. — Before  closing, we  may 
briefly  allude  to  "  cholera  vaccination,"  which  was  brought  prominently 
before  professional  notice  only  a  short  time  ago.  The  subject  has  already 
created  considerable  excitement  in  Europe,  and  especially  in  Spain,  where 
the  protective  power  of  inoculation  Avith  attenuated  cholera- virus  has  been 
made  the  subject  of  recent  experimental  inquiry,  culminating  in  the  in- 
oculation of  several  human  beings. 

Dr.  Ferran  *  has  made  a  careful  study  of  the  biology  of  the  comma- 
bacillus,  and  has  even  discovered  certain  new  forms  of  development  of 
this  microbe.  But  the  main  interest  of  these  Spanish  investigations 
naturallv  attaches  to  his  inoculations  with  the  attenuated  virus  of  cholera. 
He  attempted,  as  in  vaccination,  to  produce  a  modified  form  of  the  disease, 
which  would  effectually  protect  the  individual  against  the  acquisition  of 
the  graver  malady.  While  neither  Ferran  himself  nor  his  disciples  claim 
to  have  already  achieved  unequivocal  success,  they  nevertheless  assert  that 
they  have  obtained  decidedly  encouraging  results.'' 

Dr.  Gimeno,  in  a  recent  issue  of  La  Cronica  Medica,  and  Carreras- 
Sola,  in  La  Kevista  de  las  Ciencias  Medicas,  also  contribute  articles  on 
this  new  phase  of  the  subject.  Gimeno  asserts  that  the  comma-bacillus 
of  Koch  is  only  one  form  of  development  of  an  organism,  that  does  not 
even  belong  to  the  order  of  schizomycetes.  It  should  be  classed  rather 
with  the  cryptogamic  peronosporeae,  and  since  Ferran  is  credited  Avith 
having  made  this  discovery,  it  is  suggested  in  future  to  speak  of  the  Pero- 
nospora  Ferrani,  in  jjlace  of  Koch's  comma-bacillus,  when  alluding  to  the 
microbe  of  Asiatic  cholera. 

Carreras-Sola  says  that  "  this  microphyte  vegetates  Avithout  doubt  in 
moist  earth  and  mud,  and  amongst  the  cryptogamic  vegetations  of  the 
banks  and  bottoms  of  ponds  and  rivers.  In  the  first  place,  the  medium 
being  great  and  constantly  renewed,  the  plant  has  ahvays  more  than  enough 
oxygen  and  organic  material  to  sustain  life.  On  the  other  hand,  the  prod- 
ucts of  its  denutrition  being  extraordinarily  diluted,  it  is  not  disturbed 
by  them,  Avhich  otherwise  Avould  seriol^sly  oppose  its  development.  Placed 
in  these  conditions,  and  provided  the  temperature  be  not  too  low,  it  can 

'  La  Independencia  Medica,  Barcelona,  March  1  and  11,  ISSo. 

■-  Revista  d*;  las  Ciencias  Medicas,  and  El  Siglo  Medico,  March,  1885. 


CHOLERA  VACCINATION.  395 

in  a  few  hours  give  origin  to  an  infinite  number  of  oospheres  replete  with 
comma-bacilU  producing  granulations  so  small  at  first  as  to  pass  through 
porcelain  filters  (biscuit),  Avhen  new,  and  at  a  pressure  of  less  than  a  column 
of  10  metres.  Two  drops  of  the  cultivation-fluid,  filtered  through  one  of 
these  apparatuses,  infect  in  forty-eight  hours  a  tube  of  broth  submitted  to 
a  temperature  of  98. 6"^  F.  giving  rise  to  characteristic  spirilla.  The  in- 
fluence of  low  temperatures  paralyzes  the  work  of  segmentation,  but  the 
filaments  or  spirals  already  formed,  being  still  nourished,  engender  oogonia 
wliich,  even  at  these  temperatures,  are  converted  into  oospheres  with 
granulations  which  are  transformed  into  comma-bearing  muriform  bodies, 
which  thus  complete  the  circle  of  evolution."  ' 

The  Medical  Record  of  April  11,  1885,  iii  an  editorial  account  of 
Ferran's  experiments,  says: 

''  The  first  to  submit  himself  to  this  somewhat  hazardous  experiment 
was  Dr.  Sereiiana,  who,  on  February  23  of  the  present  year,  received  an 
injection  into  each  arm  of  half  a  cubic  centimetre  of  the  attenuated  virus. 
In  less  than  three  hours,  he  states,  he  began  to  experience  severe  pain  in 
the  posterior  region  of  the  arms,  which  gradually  increased  and  rendered 
movement  of  the  limbs  difficult.  A.t  the  end  of  seven  hours  he  had  a 
slight  chill,  accompanied  by  a  feeling  of  general  languor,  elevation  of  tem- 
perature, rapid  pulse,  insomnia  and  headache.  This  condition  remained 
for  a  little  more  than  twenty-four  hours,  when  there  Avas  a  rapid  abate- 
ment of  all  the  symptoms,  both  local  and  general.  Dr.  Jacques  was  the 
second  to  receive  the  virus,  and  although  he  Avas  injected  in  one  arm  only 
with  half  a  cubic  centimetre,  his  symptoms  were  even  more  pronounced 
than  those  of  the  first  experimenter,  and  he  also  had  slight  cramps  and 
nausea.  Dr.  Bertram,  of  Eubio,  likewise  submitted  to  the  injection  and 
experienced  similar  effects.  An  examination  of  the  blood  eighteen  hours 
after  inoculation  revealed  the  presence  of  micrococci,  said  hj  Fernin  to 
be  the  first  form  assumed  by  the  comma-bacillus  when  injected  into  the 
living  organism. 

"  At  the  expiration  of  nine  days  two  of  these  persons  submitted  to  a 
reinoculation  with  negative  results,  while  four  others,  who  received  pri- 
mary inoculations  witli  the  same  attenuated  virus  at  this  time,  suffered 
from  symptoms  of  considerable  intensity.  About  two  hours  after  the 
inoculation  pain  was  felt  in  the  arms,  and  toward  evening,  the  injection 
having  been  practiced  shortly  before  noon,  the  temperature  rose,  the  pulse 
increased  in  frequency,  there  were  headache,  languor,  slight  chills,  and 
nausea.  Later  there  was  a  rapid  fall  of  temperature,  and  the  hands  and 
feet  grew  cold  and  presented  a  marbled  appearance;  at  the  same  time  the 
headache  and  nausea  increased  and  were  accompanied  by  complete  anorexia. 
Some  of  the  siibjects  had  also  slight  cramps  in  the  calves  of  the  legs.  In 
about  forty-eight  hours  all  these  symptoms  had  passed  away.  The 
highest  temperature  recorded  was  102°  F.,  and  the  pulse  125." 

Obviously  these  experiments  are  so  few  in  number  that  it  would  be 
quite  premature  to  venture  on  any  positive  conclusions  regarding  their 
value.  It  is  to  be  borne  in  mind  above  all  things  that  cholera  has  not 
hitherto  been  shown  to  be  an  inoculable  blood-disease,  in  the  sense  of 
maladies  like  septicemia,  small-pox,  anthrax,  etc.  The  alleged  discovery 
of  the  protective  influence  of  an  attenuated  cholera-virus  should  not,  there- 
fore, be  permitted  to  awaken  a  dangerous  notion  of  false  security.     It  is, 

'  London  Medical  Record,  April  15, 1885. 


30 G  ASIATIC   CHOLERA. 

of  course,  by  no  means  impossible  that  we  are  on  the  tlireshold  of  a  new 
discovery,  that  future  exi^erimenta]  research  will  prove  to  be  of  inestimable 
value.  But  at  the  present  writing  we  must  still  urge  the  rigid  enforce- 
ment of  well-known  sanitary  rules  in  preference  to  the  hypothetical  pro- 
tection conferred  by  cholera  vaccination. 

A  leading  English  journal '  expresses  its  views  regarding  this  subject 
in  the  following  words  of  warning:  "  The  profession  in  Spain  would  do 
far  more  to  protect  their  country  from  an  ejDideniic  if  they  urgently  pressed 
on  the  authorities  to  undertake  sanitary  measures  in  the  towns,  than  by 
lulling  people  into  a  fancied  security  by  spreading  the  belief  that  inocula- 
tion will  protect  an  individual  from  the  disease.  If  cholera  does  visit  Spain 
they  will  be  wofully  undeceived." 

From  the  evidence  now  before  us  we  can  only  express  our  concurrence 
in  the  opinions  just  quoted.  Nevertheless,  we  are  not  justified  in  claiming 
that  this  new  phase  in  the  life  history  of  the  cholera  microbe  is  destined 
to  remain  barren  of  beneficial  results.  But  in  dealing  with  a  subject  of 
such  supreme  importance  as  cholera  prophylaxis,  we  must  ever  be  on  our 
guard  to  avoid  confounding  alluring  possibilities  with  demonstrable  facts. 

1  The  Lancet,  May  3,  1885. 


I  ^^  D  E  X  . 


Abdomen,  the,  in  cholera,  234 
Acclimatization  in  the  etiology  of  chol- 
era, 210 
Acid,  carbolic,  see  Carbolic  ac-id 
Adultei-ated  and  tainted  food  and  chol- 
era, 214 
Age  in  the  etiology  of  cholera,  209 
Air,  impure,  and  cholei'a,  214 
Albmiiinuria  of  cholei-a,  243 
American  theories  as  to  the  natiu-e  of 

cholera,  147 
Antiquity  of  tlie  disease,  3 
Appetite^  the,  in  cholera,  233 
Army  of  the  United  States,  histoiy  of 
epidemic  cholera  in,  7  et  seq. 
U.  S.  epidemics  of  1832-1835  in,  71 
U.  S.  epidemics  of  1848-1857,    79 

et  seq. 
U.  S.  epidemic  of  1867  in,  101   et 

seq. 
U.  S.  epidemic  of  1873  in,  109  et 

seq. 
U.  S.  epidemic  of  1866  in,  88  et  seq. 
Atmosphere,  the,  and  cholera,  211 
Aural  affections  as  sequelas,  257 


B. 


Babes'  investigations  concerning  com- 
ma-bacillus, 182,  183 
Bacillus,  comma  of  Koch,  152,  153 
Bacteria  culture,  311  et  seq. 

Nedswetzky's  researches  concern- 
ing, 129 

of  cholera,  Pacini's  discoveries  con- 
cerning-, 130,  131 

of  cholei-a,  varieties,  129 
Bacterioscopy,  300 

methods  of,  311  et  seq. 
Bartholow"s  theory  of  Cholera,  149 
Bayers  water-miasm  theoiy.  119 
Bedloe's  Island,  cholei-a  at,  108 
Bed-sores  as  sequela?,  257 
Bengal  and  Calcutta,  disease  at,  5 
Bile,  the,  in  cholei-a,  245 
Bladder  after  death  in  reaction,  286 

at  autopsj',  275 


Blood  in  cholei-a,  236 

in  cholera  ante  and  post  mortem 

researches,  276,  277 
-poison  theorj'  of  Johnson,  121 
Bombay,  cholera  in,  in  1883,  58 

mortalitv     rates,     monthly    from 
1848-1883,  59 
Bontius,  3 

Brain  and  meninges  after  death  in  re- 
action, 288 
Bronchi  at  autopsy,  278 
Bronchitis,  in  cholera,  238 
Brooklyn,  cholera  in,  in  1866,  39,  40 
Brydeii's  monsoon  tiieory,  123 

C. 

Cabul  and  Herat  -as  starting  places  of 

cholei"a,  42,  43 
Cadaver,  appearance  of,  267 
Calcutta  and  Bengal,  disease  at,  8 
Calomel  plan  of  treatment,  383 
Canada,  cholera  in,  17 
Carbolic  acid  in  the  prevention  of  chol- 
era, 332,  333 
Causation  of  cholera,  119  et  seq. 
Causes  of  cholera  in  New  York  citj'  in 
1832,20,  21,22 
of  cholei-a,  theories,  169 
of  epidemics  in  the  U.  S.  in  1847- 
1849,  28-30 
Cerebi-al  symptoms  of  cholei'a,  245 
Chapman's  ' '  neurotic  "  theorv  of  chol- 
era, 143 
Chicago,  cholei-a  in,  in  18-52,  33 
Ciiildbed  and  pregnancy  as  influenced 

by  cholei'a,  263 
Chlorides,  metallic,  in  the  prevention 

of  cholera,  332 
Chloroform  in  cholera,  379,  380 
Cholera-bacillus  controversy,  1 76 
culture,  311  et  seq. 
see  also  comma-bacillus 
-bacteria,  varieties,  129 
blood  in,  236 
cells,  125 
cyanosis,  241 
diarrhoea,  220 
eruptions,  254,  255 


398 


IXDEX. 


Cholei'a  exanthemata,  234,  255 

germs,  destruction  of,  325  et  seq. 

hygiene  as  apphed  to  miUtiirv  hfe, 
^361 

on  shipboard,  113  et  seq. 

relapses,  254 

-sweat,  241 

typhoid,  259 

and  unyniia,  diagnosis,  261 

typhoid,  blood  in,  259 

frequency,  262 

pr(jgnosis,  309 

symptoms,  259 
Choleraic  diarrhoea,  220 
Cholerine,  221 

sj'mptoms  and  variety,  221 

tlieory  of  Farr,  120 

treatment,  373 
Circulation,  organs  of,  symptoms  ref- 
erable to,  234 
Coldness  as  a  symptom,  225 
Collapse,  stage'  of,  223 
Colonies  of  comma-bacilli,  155 
Comma-bacilli,     antagonists     to     the 
growth  of,  158 

cultivation  of,  154,  155 

growth  of,  157 

bacillus.  Babes'  investigations  con- 
cerning, 183 

controversy,  the,  176 

Doyen's  researches  concerning  the, 
186 

first  discovery  of,  125 

Frencli    investigations    regarding 
170,  171 

in  the  etiologv  of  cholera,  168-169 

of  Koch,  152-154 

see  also  cholera-bacillus 

theory,  Klein's  objections  to,  180, 
181' 

of  Koch,  recent  \'iews  concerning, 
for  and  against,  194-197 

Van  Ermeugem's  reseai'ches,  186, 
187 
Complications,  254  et  seq. 

treatment  382 
Conditions  iayoring  origin  and  dissemi- 
nation of  cholera,  208 
Conjunctivaj,  diseases  of  as  sequelse,  256 
Conklin,  39 

Constipation  as  a  sequela,  257 
Contagiousness,  Budd's  \news  on,  202 

Goodeve's  opinion  on,  200 

Griesinger  s  views  on,  203 

Lebert's  opinions,  202 

Mireur's  idea  of,  204 

of  cholera,  198 

Stille's  views  upon,  203 

various  views  concerning,  200.  201 

\'iews  of  Parisian  Academy  upon. 

Convalescence,  pei-spiration  during,  256 
Cornea,  diseases  of,  as  sequelae,  256 
CoiTosive  sublimate  in  preventioii  of 
cholera,  328-330 


Cosmical  influences  in  the  etiology  of 

cholera,  212 
Course,  248 
Cramps,  choleraic,  224 

muscular,  246 
Croupous  inflammations  as  a  sequela, 

256 
Cultivation  of  comma-bacilli,  154 
Culture  of  bacilli  and  bacteria,  311    et 

seq. 

D.    . 

"Decomposing-  dejections"  theory,  122 
Destruction  of  cholera  germs,  325  et 

seq. 
Diagnosis,  diflerential,  303-305 
general  remarks,  293-295 
points  in  the,  301-303 
Diarrhoea  as  a  sequela,  257 
cholei-aic,  220 

ingredients  and  frequency',  228,  229 
premonitoi-y,  and  cholerine,  373 
Diet  after  cholera,  382 
Differential  diagnosis,  303-305 
Digestion,  organs  of,  symptoms  refer- 
able to,  228 
Diphtheritic  inflammation  as  a  sequela, 

256 
Diploe  at  autopsy,  278 
Discharges,  number  of,  224 
Diseases  witli  which  cholera  maj'  be 

confounded,  303-305 
Disinfection   external,  various   means 
of,  326-333 
internal,  various  means  of,  333  et 
seq. 
Doj'en's     researches    concerning    the 

comma-bacillus,  186 
Dr3'  autl  moist  heat  in  preventing  chol- 
era, 327 
Dyspnoea  of  cholera,  238 

E. 

Ear,  diseases  of,  as  sequelae,  257 
Early  English  accoimts,  4 
East  Indian  epidemic  of  1817,  6 
Egypt,  cholera  in,  in  1883,  61 
Electricity  in  the  etiologj'  of  cholera, 

212 
Elevation  above  the  sea  and  cholera, 

213 
Emmerich's  microbe,  190  et  seq. 
Encephalon  at  autopsy,  279 
England,  epidemic  in,  m  1831,  13 
English  accounts,  4 

epidemic  of  1831,  13 
Epidemic  in  New  York  city  in  1832,  17 

in  the  U.  S.  in  1873,  45 

in  the  U.   S.  in  1873,  jDrogress  of, 
46-48 

of  1817,  6 

of  1827  in  India,  10 

of  1866  m  the  U.  S.,  35 

of  1873  in  the  U.  S.,41 


INDEX. 


399 


Epithelial  desquamation  of  intestines 

in  cholera,  273 
Eruptions  in  cholera,  254,  2.")5 
Etiolog7v%  acclimatization  in,  210 

age  in,  209 

cosmical  influences  in,  213 

electricity  in,  212 

elevation  above  sea-level  in,  213 

general  atmospheric  conditions  in, 
211 

summai"^',  215 

habits  in,  209 

impure  air  in,  214 

water  in,  213 

occupation  in,  209 

of  cholera,  119  ef  seq. 

the  comma-bacillus  in,  168,  169 

ozone  in.  212 

poverty  in,  208 

previous  health  in,  210 

psychical  influences  in,  211 

sex  in,  208 

soil  in,  the,  212 

tainted  and  adulterated  food  in,  214 

theoi-ies,  119 
Europe,  cholera  in,  1848-1854,  33 
Evacuations,  analysis  of,  250 
Exanthemata  as  sequelae,  254 
Excrenientitious  poison  theory  of  Snow, 

120 
Experiments  of  Koch  with  tlie  comma- 
bacillus  162-164 
External  disinfection    for   preventing 
cholera,  326,  327 


Earr's  cholerine  theory,  120 

Fermentation  theory,  120 

Ferran's  experiments  with  regard  to 

inoculation,  395 
Firet  discovery  of  comma-bacillus,  125 

epidemic  in  the  U.  S.  in  1832,  16 

fatal  cases  in  N.  Y.  city,  in  the 
epidemic  of  1866,  37 
Flint's  theory  of  cholera,  149 
Food,    tainted    and    adulterated,    and 

cholera,  214 
Fort  Harper,  cholera  at,  106,  107 
France,  cholera  in,  in  1832,  15 

cholera  in,  in  1883  and  1884,  67 
French   investigations    regarding    the 

comma-bacillus,  170,  171 
Frolic,  cholera  on  board  the,  115 
Fungus  of  cholera,  peculiar,  126,  127 

G. 

Gall-hladder  at  autopsy,  224 

Gangrene  as  a  sequela,  257 

Ganjam,  disease  at,  4 

Gastro-intestinal  derangements  as  se- 
quelae, 257 

General  atmospheric  conditions  in  tlie 
etiology  of  cholera,  311 
introduction  to  symptoms,  319 


Genei-al  secretions  in  cholera,  244 

Generation,  organs  of,  in  cholera, 
symptoms  referable  to,  345 

Genitals,  female,  after  death  in  reac- 
tion, 386,  287 

Germs  of  cholera,  destruction  of,  325 
et  seq. 

Glands,  mesenteric,  at  autopsy,  374 

Glandular  structures  of  the  intestines 
at  the  autopsy,  273 

Ghxosuria  in  cholera,  247 

Goodeve's  views  of  tlie  contagiousness 
of  cholera,  200 

Governor's  Island,  cholera  on,  88,  93 

Great  epidemic  of  1817,  6 

Griesingei-'s  views  on  contagiousness  of 
cholera,  203 

H. 

Habits  in  the  etiology  of  cholera,  209 

Harris,  37 

Hastings,  7 

Heart  after  death  in  reaction,  287 

at  autopsy,  276 
Heat,   dry  and   moist,   in    preventing 

cholera,  337 
Herat  and  Cabul  as  starting-places  for 

cholera,  42,  43 
cholera  in,  10,  11 
Historv  of  cholera  epidemics  from  1500- 

1800,  3-15 
of  cholera  in  India,  3 
of  first  cholera  in  United  States,  16 
Hospital  statistics  of  mortaUty,  249-251 
Hunter,  65 
Hydrogen  peroxide  in  the  prevention 

of  cholera,  333 
Hvgiene,  cholera,  as  applied  to  militarv 

hie,  361 
Hypochlorites  of  lime  and  soda  in  the 

prevention  of  cholera,  331 


Ihsch's  theory,  122 
Impure  air  and  cholera,  214 

water  and  cholei'a,  213 
India,  cholera  in,  from  1 848-1854,  32 

epidemics  from  1830-1845,  26,  37 

history  of  cholera  in,  3 
Indian  epidemic  of  1817,  6 

of  1837,  10 

epidemics,  3 
Inflammations,  vai'ious,  as  sequela?,  256 
Inoculation,  protective,    against    chol- 
era, 340 
Integument  in  cholera,  40,  241 
International  notification  in  regard  to 

the  spi'ead  of  cholera,  340 
Intestine,  large,  at  autopsy',  273 

small,  at  autopsy,  270 
Intestines  in  cholera,   Koch's  descrip- 
tion of,  152,  153 
Ipecacuanha  metliod  of  treatment,  384 


400 


INDEX. 


Investigations  of  Babes  on  the  comma- 
bacillus,  183-185 

Italian   views   concerning  the  cholera- 
bacillus,  178 

Italv,  cholera  in.  in  1834,  15 
"in  1883-84,  67 


Johnson's  blood-poison  theory,  121 

K. 

Kidnevs  after  death  in  reaction,  281- 
286 
at  autopsj',  275 
Kiehl's  theory,  121 

Klein's  objections  to  the    comma-ba- 
cillus theory,  180-181 
Koch's  comma-bacilli,  152,  153,  154 
comma-bacillus      theory,      recent 
views      concerning,      for      and 
against,  194-197 
description    of    the    intestines    in 

cholei'a  152,  153 
experiments  with  the  comma-ba- 
cillus, 162,  164 
researches  in  Egypt,  151  et  seq. 


Lackawanna,  cholera  on  board  the,  114 
Large  intestine  after  death  in  reaction, 
281 

at  autopsy,  274 
Lebert,  275 

Leberfs  theory  of  cholera,  145-147 
Lewis  and   Cunningham's  views  con- 
cerning the  cause  of  cholera,J134 
Lime  and  soda  hypochlorites  in  the 

pi'evention  of  cholera,  330-332 
Little  Rock  barracks,  cholera  at,  96 
Liver  after  deatli  in  reaction,  281 

at  autopsy,  274 
Loomis'  theory  of  cholera,  148 
Lungs  after  death  in  reaction,  287,  288 

at  autopsy,  278 

M. 

Mackie,  63 

Macnamara's  views  as  to  the  natvue  of 
cholera,  135,  136 

Magnon's  experiments,  171 

Malarial  theory  of  cholera,  134 

Marseilles  commission,  results  of,  173 

Mauiin  and  Lange's  experiments  con- 
cerning etiologj'  of  cholera,  147, 
175 

]\Iedical  inspection  and  the  spread  of 
cholera,  345 

Jleninges  at  autopsj',  278 

Mercuric  chloride  in  the  prevention  of 
cholera,  328,  330 

Mesenteric  glands  after  death  in  reac- 
tion. i'Si 
at  autopsy,  274 


Metallic    chlorides    in    prevention    of 

cholera,  332 
Methods  of  bacterioscopy,  311  et  seq. 
Microbe  of  Emmericli,  liie,  190  et  seq. 
Militaiy  life,  cholera  hygiene  in,  361 
Mireur's  views  on  the  contagiousness 

of  cholera,  204 
Missouri,  cholera  in,  in  1848-ia53,  30,  31 
Monsoon  tlieory  of  Bryden,  123 
Montreal,  cholera  in.  18 
Morbid  anatomy,  267  et  seq. 

blood,  276 

bronchi.  278 

diploe.  278 

encephalon,  279 

heai't  and  endocai'dium,  276 

kidneys,  275 

large  intestine,  273 

larnyx,  278 

liver,  274 

lungs,  278 

meninges,  278 

mesentei'ic  glands,  274 

ovai'ies,  276 

pericardium,  276 

peritoneum,  269 

pharnyx  and  oesophagvis,  370 

pleura,  276 

small  intestine,  270 

spleen,  274 

stomach,  270 

trachea,  278 

vagina,  276 

(death  in  reaction,)  bladder,  286- 

brain  and  its  membranes,  288 

female  genitals,  286,  287 

heart,  287 

kidneys.  281-286 

large  intestine,  281 

hver.  281 

lungs,  287.  288 

mesenteric  glands,  281 

peritoneum,  280 

small  intestine,  281 

spinal  cord  and  membi-anes,  288 

spleen,  281 

stomach,  280 

appearances  after  death  during  re- 
action, 280 
Moi'ehead,  198 
Morphine  in  cholera,  379 
Mortality,  248,  249 
Moscow,  epidemic  in,  12,  13 
Mouth,  temperature  of,  240 
Municipal  measures  for  prevention  of 

cholera,  355 
Murray,  206 
Muscles,  post-mortem  contraction  of, 

268 
Muscular  cramps  in  cholera,  246_ 


National  responsibility  regarding  the 
spread  of  cliolera,  339 


INDEX. 


401 


Nature  of  cholera,  American  theories, 
147 
Koch's  theory  of,  lol 
Lebert's  theory,  145-147 
Macnaraara's  theory-,  135-138 
neurotic  theory,  143 
Pettenkofer's  theory,  139 
theories,  134  et  seq. 
Necropsy,  the,  269 
Nedswetzky's    researches    on    cholera 

bacteria,  129 
Nervous  system,  symptoms  referable 

to,  245 
Neurotic  theoiy  of  cholera,  14B 
New  Orleans,  cholera  in,  in  1832,  24,  25 
New  York  city,  cholera  in,  in  1832,  17 
in  1832,  causes  and  theories  regard- 
ing, 20-24 
distribution  of  the  first  fatal  cases 
in  1866,  37 
Nicati  and  Rietsch's  experiments,  con- 
cerning the  etiology  of  cholei-a, 
174 

O. 

Occupation  in  the  etiology  of  cholera, 
209 

Ocular  troubles  as  sequela?,  256 

(Esophagus  at  post-mortem,  270 

Origin   and   dissemination  of   cholei"a, 
conditions  favoring,  208 

Organic  dust  theory  of  Von  Gietl,  123, 
124 

Organs  of  circulation,  symptoms  refer- 
able to,  in  cliolera,  234 
respiratory,  symptoms  referable  to, 

237 
urinarj',    symptoms    referable   to, 
242,  243 

Ovaries  at  autopsy,  276 

Ozone  in  the  etiology'  of  cholera,  212 
theories,  123 

P. 

Pacini's  discoveries  regarding  cholera- 
bacteria,  130,  131 
Paralysis  as  a  sequela,  257 
Parasitic  theories  of  cholera,  125 
Paresis  as  a  sequela,  257 
Paris  Academy  of  Medicine,  discussion 

in  concerning  cholera,  199,  200 
cholera  in,  in  1832,  14 
Parotitis  as  a  sequela,  257 
Percentage  of  mortality,  249-251 
Pericardium  at  autopsy,  276 
Period  of  attack,  symptoms,  233 
Peritoneum    after"  death    in  reaction, 

280 
the,  269 
Peroxide  of  hydrogen  in  the  prevention 

of  cholera,  333 
Pei-sia,  cholera  in,  11 
Personal  prophylaxis  for  prevention  of 

cholera,  356,  357 
26 


Perspiration  in  convalescence,  256 
Pettenkofer's  views  as  to  the  nature  of 

cholera,  139-143 
Pharynx  at  post-mortem,  270 
Philadelphia,  cholera  among  troops  in, 

95 
Pleura  at  autopsy,  276 
Polyuria  in  cholera,  244 
Port  Said,  cholera  at,  62 
Post-mortem  contraction  of  muscles, 

268 
Potomac,  cholera  on  board  the,  113 
Poverty  in  the  etiology  of  cholera,  208 
Poznanski's  plan  for  treating  cholera, 

393 
Practice  of  quarantine,  by  land,  349 
by  sea,  347 
in  foreign  ports,  354 
Pregnancy  and  cliildbed  as  influenced 

by  cliolei*a,  263 
Prevention  of  the  spread  of  cholera,  339 

et  seq. 
Previous  health  in  the  etiology  of  chol- 
era, 210 
Prodromal    stage,   symptoms    during, 

223 
Prognosis,  248  et  seq. 

during-  the  attack,  306 
during  the  period  of  reaction,  308 
in  the  typhoid  condition,  309,  310 
Protective  inoculation  against  cholera, 

394 
Psychical  influencss  in  the  etiology  of 

cholera,  211 
Pulse,  description  of,  225 
the  in  cholera,  235 

Q, 

Quarantine,  practice  of,  by  land,  349 
practice  of,  by  sea,  347 
practice  of,  in  foreign  ports,  854 
theory  of,  345 

Quebec,  cholera  in,  16 

R. 

Reaction,  death  in,  morbid  appearan- 
ces, 280  et  seq. 
stage  of,  226 
prognosis,  308 
treatment,  382 
Recent  \news  of  the  Paris  Academj*, 

199-201 
"  Reizfieber,"  260 
Relapses,  254 

treatment,  383 
Respirations,  225 

Respiratory  organs,   symptoms  refer- 
able to,  237 
Responsibility  of  nations  regarding  the 

spread  of  cholera,  339 
Results   of  the  Marseilles  commission 

on  cholera,  173 
Rice-water  stools,  224 
Rigor  mortis,  267 


402 


INDEX. 


Russia,  cholera  in,  in  1830,  12,  13 

in  1869,  44 
Russian  epidemic,  the  great,  12,.  13 

S. 

St.  Louis,  cholera  in,  in  1848-1853,  30,  31 
Secretions,  general,  in  cholera,  244 
Semmola,  379 
Sequelae,  aural  affections,  257 

of  cholera,  254 

treatment,  382 
Serenana's  experiments  in  regard  to 

inoculation,  395 
Sex  in  the  etiology  of  cholera,  208 
Shipboard,  cholera  on,  113  et  seq. 
Ships,  cholera  in,  113  et  seq. 
Small  intestine  after  death  in  reaction, 
281 

at  autopsj',  270 
Snow's  excrementitious  poison  theory-, 

120 
Soda  and  lime  hypochlorites  in  the  pre- 
vention of  cholera,  330 
Soil  in  the  etiology  of  cholera,  212 
Soldiei's,    hygiene    of    for    preventing 

cholera,  361 
Southern  States  of  U.  S. .  cholera  in,  in 

1873,  49-51 
Spain,  cholera  in,  in  1832,  15 

cnolera  in,  in  1883-1884,  67,  68 
Special  methods  of  treatment,  383 
Spinal  cord  and  its  membranes  after 
death  and  reaction,  288 

at  autopsy,  279 
Spleen  after  death  in  reaction,  281 

at  autopsy,  274 
Sporadic  cholera  cases,  295-297 
Spread  of  cholera,  prevention,339  et  seq. 
Stage  of  collapse,  223 

of  reaction,  226 

the  prodromal,  symptoms  of,  223 
Stages  of  cholera,  varieties,  222 
Stille's  views  on  the  contagiousness  of 

cliolera,  203 
Stomach  after  death  in  reaction,  280 

at  autopsy,  270 

disorders  as  sequelte,  257 
Stools,  rice-water,  224 
Suez  canal,  cliolera  near,  61 
Sulphur  dioxide  in  the  prevention  of 

cholera,  332 
Summary  of  etiological  factors,  215 
Sweat,  profuse  in  convalescence,  256 
Symptoms  abdominal,  234 

albuminuria,  243 

appetite,  233 

blood,  236 

bronchitis,  238 

cerebral,  245 

cramps,  246 

cyanosis,  241 

diarrhoea,  228-233 

dyspnoea,  238 

general  remarks,  219 


Symptoms,  general  secretions,  244 

glycosuria,  244 

integument,  240,  241 

nervous,  245 

of  prodromal  stage.  222,  223 

of  the  period  of  attack,  223 

organs  of  generation,  245 

polyuria,  244 

referable  to  the  organs  of  diges- 
tion, 228 

state  of  tongue,  233 

sweat,  241 

temperature,  239 

the  pulse,  235 

thirst,  233 

urinary,  243 

vomiting,  232,  233 
Synonyms  for  cholera  in  the  East,  5 


Tainted  and  adulterated  food  and  chol- 
era, 214 
Temperature  in  cholera,  239 

regional,  in  cholera,  240 
Tennessee,  cholera  in,  110 
The  United  States  Armj',  epidemics  of 

1832-1835  in,  71 
Theories  of  cholera,  American,  147 

of  cholera's  cause,  119  e^  seq. 

parasitic,  of  cholera,  125 
Theory  of  decomposing  dejections,  122 

of  the  cause  of  cholera,  119  et  seq. 

of  the  nature  of  cholera,  Koch's, 
151  et  .seq. 

of  quarantine,  .345 
Therapy;  see  Treatment. 
Thirst  in  cholera,  233 

in  the  symptoms,  224,  225 
Thoracic  duct  at  autopsy,  274 
Tongue,  appearance  of,  224 

the,  in  cholera,  233 
Trachea  at  autopsy,  278 
Treatment,  acids  in,  374 

calomel  method,  383 

Cantani's  plan,  391 

chloroform  in,  379,  380 

diet,  382 

during  reaction,  882 

general  remarks,  369 

Hayem's  views,  387 

ipecacuanha  method,  384 
.  Lereboullet's  plan,  389,  390 

morphine  in,  379 

of  a  well-marked  case,  378 

of  complications,  382 

of  premonitory  diarrhoea  and  chol- 
erine, 373 

relapses.  382 

of  sequeke,  882 

opium  in,  375 

Samuel's  plan,  891 

Senimola"s,   or   the    physiological 
plan,  386 

special  methods,  883 


INDEX, 


'^'-^^f^v 


403 


Tj'phoid  cholera  in  Egj'pt,  63 

U. 

Ulceration  of  the  cornea  as  a  sequela, 

256 
Ulcers  as  sequelae,  257 
United  States  Armv,  cause  of  the  chol- 
era in,  in  1832,  73-77 
epidemics  of  1848-1857,  79  et  seq. 
epidemic  of  1866  in,  88  et  seq. 
epidemic  of  1867  in,  101  et  seq. 
epidemic  of  1873  in,  109  et  seq. 
history  of  cholera  in,  71,  et  seq. 
United  States,  cholera  in,  from   1848- 
1854,  32 
cholera  in,  in  1873,  45. 
epidemic  in,  in  1848,  1849,   27,  28, 

29,  30 
epidemic  of  1866,  35 
epidemic  of  1873,  41 
fii"st  epidemic  in,  in  1832,  16 
Urfemia  and  cholera  typhoid  diagnosis, 
261 


Ureters  at  autopsy,  375 

Urinary  organs,   symptoms    referable 

to,  242  . 
Urine,  in  cholera,  analysis  of,  243 
Utei-ine  bleeding  in  cholera,  245 
Uterus  at  autopsy,  275 


Vagina  at  autopsy,  276 
Van  Evmengem's  researches  concern- 
ing the  comma-bacilkis,  186,  187 
Vomit,  choleraic,  analysis  of,  232,  233 
Vomiting,  224 

as  a  sequela,  257 
Von  Gietl's  organic-dust  theory,  123 
Vox  choleraic,  239 

W. 

"Water,  impure,  and  cholera,  2,  3 

tlie,  224 
Water-miasm  theory  of  Bayer,  119 
Woodivard,  207 


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MANUAL  OF  GYNECOLOGY.  By  D.  BENJ.  HART,  M.D.,  F.R.C.P.E.,  Lecturer  on  IfiduH/erv 
and  Disease*  of  Woman,  School  of  Ifedicine,  Edinburgh,  etc.,  etc.;  and  A.  H.  BARBOUR,  M.A.,  B.Sc, 
tlL.'R.,  Assistant  to  the  Professor  of  Midwifery,  University  of  Edinburgh.  Volume  I.  Illustrated  with 
eight  plates,  two  of  which  are  in  colorB,  and  192  fine  wood  engravings. 

MANTTAL  OF  GYNECOLOGY.  By  D.  BENJ.  HART,  M.D.,  F.R.C.P.E.,  Lecturer  on  Midwifery 
and  Diseases  of  Women,  School  of  Medicine,  EdiJiburgh,  etc.,  etc.;  and  A.  H.  BARBOUR,  M.A.,  B. 
Sc.,'^.'B.,  Assistant  to  the  Professor  of  Midioifery,  University  of  Edinburgh.  Volume  II.  Illustrated 
with  a  lithographic  plate  and  209  fine  wood  engravings. 

THE  DISEASES  OF  WOMEN.  A  Manual  for  Physicians  anrt  Students.  By  HEINRICH  FRITSCH 
M.D.,  Professor  of  Gynecology  and  Obstetrics  at  the  University  of  Salle.  Translated  by  ISIDORE 
FURST.     Illustrated  with  150  fine  wood  engravings. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.  By  WM.  B.  CARPENTER,  C.B.,  M.D.,  LL.D. 
Sixth  Edition.  Volume  I.  Illustrated  by  one  colored  and  26  plain  plates,  and  502  fine  wood 
engravings. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.  By  WM.  B.  CARPENTER,  C.B.,  M.D.,  LL.D. 
Sixth  Edition.    Volume  II.    Illustrated  with  26  plates  and  502  fine  wood  engravings. 

HANDBOOK  OF  ELECTRO-THERAPEUTICS.  By  DR.  WILHELM  ERB,  Professor  in  the  Univer- 
sity of  Leipzig.     Illustrated  by  3!t  wood  engravings. 

A  TEXT-BOOK  OF  GENERAL  PATHOLOGICAL  ANATOMY  AND  PATHOGENESIS.  By 
ERNST  ZIEGLER,  Professor  of  Pathological  Anatomy  in  the  University  of  TUbingen.  Translated 
and  edited  for  English  students  by  DONAL  McALISTER,  A.M.,  M.B.,  Member  of  the  Royal  GoUege  of 
Physicians  ;  Fellow  and  Medical  Lecturer  of  St.  John's  College,  Cambridge. 

THE  TREATMENT  OF  WOUNDS.  Being  a  Treatise  on  the  principles  upon  which  the  Treatment  of 
Wounds  should  be  founded,  and  on  the  best  methods  of  carrying  them  into  practice,  including  a  con- 
sideration of  the  modifications  which  special  injaries  may  demand.  By  LEWIS  S.  PILCHER,  A.M., 
M.D.,  of  Brooklyn,  N.  Y.     Illustrated  by  wood  engravings. 

A  MANUAL  OF  PRACTICAL  HYGIENE.  By  EDMUND  A.  PARKES,  M.D.,  P.R.S.,  Late  Pro- 
fessor of  Military  Hygiene  in  the  Army  Medical  School ;  Member  of  the  General  Council  of  Medical 
Education  ;  Fellow  of  the  Senate  of  the  University  of  London ;  Emeritus  Professor  of  Clinical  Medi- 
cine in  University  College,  London.  Edited  by  P.  S.  FRANCOIS  DeCHAUJJONT,  M.D.,  F.R.S., 
Fellow  of  the  Royal  College  of  Surgeons,  Edinburgh  ;  Felloio  and  Chairman  of  the  Sanitary  Institute 
of  Great  £rUain;  Professor  of  Military  Hygiene  in  t/ie  Army  Medical  School.  Sixth  Edition, 
Volume  I. 

A  MANUAL  OF  PRACTICAL  HYGIENE,  WITH  AN  APPENDIX.  Giving  the  American 
practice  in  matters  relating  to  Hygiene,  prepared  by  and  under  the  supervision  of  FREDERICK  N. 
OWEN,  Civil  and  Sanitary  Engineer.     Illustrated  by  chromolithographic  plates.     Volume  II. 

ON  SYPHILIS  IN  INFANTS.  By  PAUL  DIDAY.  Translated  by  DR.  G.  WHITLEY.  With  Notes 
and  Additions  by  F.  R.  STURGIS,  M.D.     With  a  Colored  Plate. 

t^~  In  bringing  oat  an  American  edition  of  Diday's  exceptional  work.  Dr.  Sturgis  in  his  prcfare 
says:  "He  believes  that  this  method  of  annotation  will  serve  to  bring  out  many  points  in  the  Pathology 
and  Treatment  of  Infantile  Syphilis  better  than  it  could  have  done  in  an  independent  work." 

A  TREATISE  ON  VETERINARY  MEDICINE,  as  Applied  to  the  Diseases  and  Injuries  of  the 
Horse.  Compiled  from  standard  and  modem  authorities.  By  F.  O.  KIRBY.  Illustrated  by  4  chromo- 
lithographic plates,  containing  numerous  figures  and  about  150  fine  wood  engravings. 


WOOD'S  Library  of  [Standard  Medical  Authors. 

Fourth  Series.    Price,  $1S.00.   Yolunies  not  sold  separately. 

ILLUSTRATIONS   OF   DISSECTIONS.     In  a  series  of  original  colored  plates,  representing  the  dissec- 
tions of  the  human  bdly,  -n-ith  descriptive  letter-press.     By  GEORGE   YINER  ELLIS,  Professor  of  ' 
Anatomy  in  Vniveisity  College.  London,  and  G.  H.  FORD,  Esq.     The  drawings  are  from  nature  by  e 
Mr.  Ford,  from  directions  by  Prof.  Ellis.      Volume  I.     Containing  29  full  page  chromo-lithographic  • 
plates.  9 

ILLUSTRATIONS  OF  DISSECTIONS.     In  a  series  of  original  colored  plates,  representing  the  dissec-  i 
tions  of  the  human  body,  with  descriptive  letter-press.      By  GEORGE  VIXER  ELLIS,  Professor  of 

Anatomy  in  I'niversUi/ College,  Lo2idon,  and  Cr.  U.  TOBD, 'Esq.    Volume  II.     Containing  27  full- page  *• 

chromo-Uthographic  plates.  S 

^S°°  ^^^len,  in  the  second  series,  we  succeeded  in  presenting  our  subscribers  with  "  Savage's  Female  B 

Pelvic  Organs,''  with  its  full-page  lithographic  plates,  we  supposed  we  had  reached  the  extreme  Umit  in  "3 

reproducing  expensive  books  at  so  low  a  price,  but  these  two  volumes  of  Ellis  and  Ford  far  exceed  even  S 

that.     It  is  simply  wonderful,  and  cannot  fail  to  compel  acknowledgment  of  the  value  of  this  series  of  S 

pubhcations.     It  would  have  been  impossible  to  accomplish  such  resvilts,  save  in  a  library  such  as  this,  * 
in  which  all  the  volumes  have  a  large  and  equal  sale. 

LECTURES  ON  DISEASES  OF  CHILDREN.     A  Hand-book  for  Physicians  and  Students.     By  Dr.  " 

EDWARD    HENOCH,  Director  of  the  Clinic  and  Polyclinic  for  IH-^eases  of  Children  in  the  Royal  2 
Chaute  Hospital  and  Professor  in  the  Berlin  University.     Translated  from  the  German.      13^  A  new 

book,  just  ready,  and  of  great  practical  value,  ^ 

MATERIA  MEDICA    AND    THERAPEUTICS.      Inorganic    Substances.      Ey  CHARLES    D.   F.  9 
PHILLIPS,  M.D.,  F.R.C.S.E.,  Lecturer  on  Materia  Medica.  Westmin.ster  Hospital.  London.    Adapted 

to  the  United  States  Pharmacopoeia.     By  LAWRENCE  JOKN'SOX,  M.D.     Volume  I.  * 

MATERIA    MEDICA    AND    THERAPEUTICS.     Inorganic    Substances.      By   CHARLES    D.    F.  5 

PHILLIPS,  M.D.,  F.R.C.S.E.,  Lecturer  on  Materia  it edi'  a,  Westminster  Hospital,  London.     Adapted  . 

to  the  United  States  Pharmacopoeia.     By  LAWREXCE  JOHNSON.  M.D.     Volume  II.  « 

gasgr-  Since  the  publication  of  the  learned  author's  treatise  on  the  Materia  Medica  and  Therapeutics  of  C 

the  vegetable  kingdom,  in  the  first  series,  there  has  been  a  continued  inquiry  for  this  promised  con-  • 

tinuation.     We  are  happy  to  be  able  now  to  present  it  fresh  from  the  hands  of  Dr.  Phillips,  and  pub-  im 

lished  in  Wood's  Librars-,  bv  special  arrangement  with  him.  -  . 

PRACTICAL   MEDICAL  ANATOMY.    A  guide  to  the  physician  in  the  Study  of  the  Relations  of  the  e^ 

Viscera  to  each  other  in  Health  and  Disease,  and  in  the  Diagnosis  of  the  Medical  and  Surgical  Conditions  ,»• 

of  the  Anatomical  Structures  of  the  Head  and  Trunk.     By  AMBROSE  L.  RANNEY,  A.M..  M.D.,  Ad-  "Cp, 

junct  Profes-tor  of  Anatomy  and  late  Lecturer  on  Genito-urinary  and  Mi7ior  Surgery  in  the  Jfedical  ?ft 

Department  of  the  University  of  the  City  of  New  York;  late  Surgeori  to  the  Nurthern  and  X^rth-  ©  S 

western  Dispensaries ;  Resident  Felloic  of  the  Kew  York  Academy  of  Medicine  :  Member  of  the  Medi-  »«• 

cat  Society  of  the  County  of  Hew  York  ;  Author  of  '■  Ihe  Applied  Anatomy  of  the  Keitous  System,^'  ^  9 

"4  Practical  Treatise  on  Surgical  Diagnosis,'''  '■'■The  Essentials  of  Anatomy,^''  etc.,  etc.    Illustrated  *>* 

by  fine  wood  engravings.  *"  g 

f^^  This  work  occupies  a  new  field  in  Anatomy  of  an  e.Kceedinslv  practical  character.  ^^es 

MENTAL   PATHOLOGY  AND   THERAPEUTICS.     By   W.   GRIESINGER,    M.D.,    Professor  of  S» 

Clinical  Medicine  and  of  Medical  Science  in  the  University  of  Berlin  :    Honorary  Member  of  the  *9  9 

Medico- Physiological  Association  ;   Membre  Aasocie  Stranger  de  la  Societe  Medico- Physiologigue  de  "  !; 


Paris,  etc.,  etc.    Translated  from  the  German  by  C.  LOCKHART  ROBERTSON.  M.D..  Cantab,  Medical 


hO 


Superintendent  of  the  Sussex  Lunatic  Asylum,  Haywards  Heath,  and  JAMES  RUTHERFORD,  M.D.,  §,8 
Edinburg.  © 

^^~  The  first  edition  of  this  standard  work  appeared  in  184.5,  and  coming  from  the  acknowledged  J,  9 

leader  of  the  modem  German  school  of  Medical  Psychology,  it  at  once  became  the  recognized  authority  es 

upon  the  subject  of  which  it  treats.     The  various  editions  and  translations  since,  have  maintained  its  n 

high  position  and  enhanced  the  estimation  in  which  it  is  held  bv  all  students  of  medical  metaphysics.  » 

DISEASES   OF    THE   RECTUM  AND  ANUS.     By  CHARLES   D.  KELSEY.   M.D.,  Surgeon  to  St.  "Z 

Paul's  tnjlrnuiry  for  Diseases  of  the  Rectum:  Consulting  Surgeon  for  Diseases  of  the  Rectum,  to  * 
the  Harlem  Hospital  and  Dispensary  for  Women  and  Children,  etc.,  etc. 

ON  ASTHMA:    ITS   PATHOLOGY   AND   TREATMENT.     Ey  HENTIY  HYDE  SALTOR,  M.D. ,  5 

F.R.S..  Fellow  of  the  Royal  College  of  Physicians ;  Physician  to  Charing  Cross  Hospital,  and  Lee-  fi 

turer  on  the  Principles  and  Practice  nf  Medicine,  at  the  Charing  Cross  Hospital  Medical  School.  ** 

^^~Fivst  American  from  the  last  Engli.sh  edition.  ^ 

RHEUMATISM.    GOUT,   AND  SOME   OF   THE   ALLIED  DISEASES.      By  MORRIS   LONG-  * 

STRETH,  M.D.,  etc.  ■ 

^g""  The  work  treats  the  subject  it  relates  to,  from  an  American  stand-point,  the  works  heretofore  in  m 

the  market  being  of  foreign  origin.     It  will,  therefore,  be  a  very  practical  volume,  for  the  use  of  physi-  fl 

cians  throughout  this  country.  P, 

LEGAL  MEDICINE.     By  CHIRLES  MEYMOTT  TIDY,  M.B.,  F.C.S..  Jfaster  of  Surgery.  Professor  ^ 

oj  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  Medical  Officer  of  p. 

Health  for  Islington,  Late  Deputy  Medical  Officer  of  Health  and  Public  Arialyst  for  the  City  of  Lon-  ^ 

don,  etc.     Volume  I.     With  two  colored  plates.     Contents  ;    Evidence — The  Signs  of  Death — Identity —  ^ 

The  Causes  of  Death— The  Post  Mortem.  e 

LEGAL  MEDICINE.     By  CHARLES  MEYMOTT  TIDY,  M.D.,  F.C.S.,  Master  of  Surgery,  Professor  ^ 

of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  Medical  Officer  oj  H 

Health  for  Islingtcm.  Late  Deputy  Medical  Officer  of  Health  and  Public  Analyst  for  the  City  of  London,  ■ 

etc.    Volume  II.    Contents:  Expectation  of  Life— Presumption  of  Death  and  Survivorship — Heat  and  » 

Cold — Burns— Ligaturing— Explosives — Starvation— Sex— Mon.=trosities—Hermaphrodi.=m.  g 

{s^~  The  need  for  a  thorough  and   exhaustive  treatise  upon  this  subject  from  some  recognized  P* 

authority  has  long  been  felt  in  Engli.sh  speaking  countries.     But  the  labor  of  prerarine  such'  a  work  is  L 

so  stupendous,  requirmg  such  critical  acumen  and  familiarity  with  both  medicine  and  law,  together  gj 
with  the  most  patient  industry,  that  even  those  more  or  less  qualified  to  undertake  the  task  have  held 
back.  It  is,  therefore,  with  no  little  satisfaction  that  the  publishers  have  been  able  to  secure  this  very 
valuable  work  for  the  subscribers  to  Wood's  Library  of  Standard  Medical  Authors.  Each  volume  is 
complete  upon  the  topics  of  which  it  treats.  Upon  cimpleti.in.  subscribers  will  pos.=«ss,  at  a  nominal 
cost,  the  fullest  and  most  thorough  treatise  on  the  subject  of  modern  times. 

It  will  interest  our  subscribers  to  know  that  the  cost  of  the  two  volumes  we  now  present,  is,  in  the 
original  English  edition,  over  $13.00. 


.e 


<M 


Catalogue  of  the  Titles  of  Works  published  in 

WOOD'S  Library  of  Standard  Medical  Authors. 


Tliird  Series.    Priee,  $1S.00.    Volumes  not  sold  separately. 


«  ON  ALBUMINURIA.     By  W.  H.  DICKINSON,  M.D.     Illustrated  with  plain  and  colored  lithographic 

tK  plates  and  wood  engravings. 

5  t2^~  This  is  the  acknowledged  standard  upon  this  interesting  subject,  and  is  the  most  complete 

S  treatise  upon  it  in  the  language. 

«  MATERIA  MEDICA  AND  THERAPEUTICS  OF  THE  SKIN.     By  HKNRY  G.  PIFFARD,  A.M., 

S  M  D.,    Pra/eisur  of  Dermatology,  Medical  Department  of  the  Univeraity  of  the  City  of  Neio  York; 

«  Surgeon  to  Charily  Hospital,  etc. 

^  "  Morbi  epidermidem.  epithelium,  cutim,  et  cellulosam  membranum  efBcientes  tam  multi  sunt,  ut  vix 

*  in  ordinem  patiuntur  redigi :  ex  medicamentis  autem  quse  maxime  ad  eorum  morborum  curationem 
2  sunt  im  usu,  hie  proponemus." — De  Gorteii  (1740) . 

g  |^~  This  original  work  is  probably  one  of   the  most  useful   books  for  the  general   practitioner 

J  ever  published  upon  the  subject,  containing  as  it  does  a  systematically  classified  mass  of  the  most  popu- 

"w  lar  and  recent  formuJfe. 

^  A  TREATISE  ON  DISEASES  OF  THE  JOINTS.     By  RICHARD  BARWELL,  F.R.C.S.     Surgeon 

w  C/iaring-  Cross  Hospital,  etc.     Illustrated  by  numerous  engravings  on  wood. 

J"  p^"  This  standard  book,  just  re-written  by  its  distinguished  author,  is,  by  special  arrangement  with 

g  him,  published  in  this  library  in  advance  of  its  appearance  in  England. 

«  A  TREATISE  ON  THE  CONTINUED  FEVERS.     By  JAMES  C.  WILSON,  M.D.,  Attending  Phy- 

^  sician  to  the  Philadelphia  Hospital  and  to  the  Hospital  of  the  J^erson  Medical  College,  and  Lecturer 

B  .  on  Physical  Diapnosis  at  the  Jeffer.ton  Medical  College,  Fellow  of  the  College  of  fhysicians,  Phila- 

*  "O  deiphia.  etc.  With  an  introduction  by  J.  M.  DA  COSTA.  M.D.,  Professor  of  the  Practice  of  Medicine 
•>•  and  Clinical  ^fedirine  at  the  Jeffemon  Medical  College.  Physician  to  the  Pennsylvania  Hospital.  Con- 

^^  suiting  Physician  to  the  Children's  Hospital,  Felloic  of  the  College  of  Physicians,  Philadelphia,  etc. 
►•SS,  i&^~  It  would  hardly  be  possible  to  present  to  the  profession  a  work  of  more  universal  interest  than 

2  a  thi^.     Tne  volume  is  specially  prepared  for  this  series,  and  necessarily  possesses  great  practical  value 

»»  •  to  all  practitioners  of  medicine. 

MEDICAL  FORMULARY.     By  LAURENCE  JOHNSON,  A.M.,   M.D.,   Fellow  of  the   New    York 
Academy  of  Medicine,  etc. 
J? a  ^^  It's  a  long  time  since  the  first  publication  of  Ellis  and  of  Griffiths;  the  present  modem  work 

"5  **  will,  therefore,  be  peculiarly  acceptable. 

S  *     THE  DISEASES  OF  OLD  AGE.     By  J.  M.  CHARCOT,  M.D.,  Professor  in  Faculty  of  Medicine  of 

A  2  Paris  ;  Physician  to  the  Salpetriere  ;  Member  of  the  Academy  of  Medicine  ;  of  the  Clinical  Soiiety  of 

01 S  London  ;  of  the  Clinical  Society  of  Buda-Pe.ith ;  of  the  Society  of  yatural  Scie7ices,  Brussels  ;  President 

5)  g  of  the  Anatomical  Society,  etc.,  etc.    Translated  by  L.  HARRISON   HUNT.  M.D.,  with  numerous 

h  2  additions  by  A.  L.  LOOXIIS.  M.D..  etc.,  Professor  of  Pathologu  and  Practical  Medicine  in  the  Medical 

■  "  Department  of  the  University  of  the  City  of  If  etc  i'ork :  Consulting  Physician  in  the  Charity  Hospital ; 
m  to  the  Bureau  of  Out-Door  Belief;  to  the  Central  Dispensary:  Visiting  Physician  to  the  Bellevue 
iS  Hospital ;  to  the  Mount  Sinai  Hospital,  etc..  etc. 

«  ^^Tliis  work  is  upon  a  subject  little  understood,  and  but  little  treated  of  by  authors.     It  will  be 

■  almost  the  only  book  of  its  kind. 

*  COULSON  ON  THE  DISEASES  OF  THE  BLADDER  AND  PROSTRATE  GLAND.  Sixth 
5  Edition.     Revised  by  WALTER  J.  COULSON.  F.R.C.S..  Surgeon  to  St.  Peter's  Hospital  for  Stone,  etc., 

aiid  Surgeon  to  the  Lo'-k  Hospital.     Illustrated  by  wood  engravings. 
©  p^"  This  standard  work  has  just  been  revised  and  is  most  highly  commended  by  the  leading  medical 

journals  of  England. 

GENERAL  MEDICAL  CHEMISTRY.  A  practical  manual  for  the  use  of  physicians.  By  R.  A. 
WITTHAUS,  A.M.,  M.D.,  frofessor  of  Medical  Chemistry  and  Toxicology  in  the  University  of  Ver- 
mont, Member  of  the  Chemical  Societies  of  Paris  and  Berlin,  New  York  Academy  of  Medicine,  etc. 

^^  No  medical  chemistry  especially  intended  for  the  use  of  practising  physicians  has  appeared  for  a 
long  time;  it  is  therefore  believed  this  "  will  Jill  a  want  longfell.'^ 

ARTIFICIAL  ANAESTHESIA  AND  AN.S;STHETICS.  By  HENRY  M.  LYMAN,  A.M.,  M.D., 
Professor  of  Physioloijy  and  S'ei-vous  Diseases  in  Bush  Medical  College,  and  Professor  of  Theory  and 
Practice  of  Medicine  in  the  Woman's  Medical  College,  Chicago,  III. 

g^^  The  first  comprehensive  and  complete  treatise  upon  this  comparatively  modem  and  very  im- 
portant subject. 

A  TREATISE  ON  FOOD  AND  DIETETICS.  Physiologically  and  Therapeutically  considered.  By 
F.  W.  PAVY,  M.D.,  F.S.     Second  Edition. 

A  HANDBOOK  OF  UTERINE  THERAPEUTICS  AND  DISEASES  OF  WOMEN.  By 
EDWARD  JOHN  TILT,  M.D.    Fourth  Edition. 

DISEASES  OF  THE  EYE.  By  HENRY  D.  NOTES,  M.D.,  Professor  of  Ophthalmology  and  Otology 
in  Bellevue  Hospital  Medical  College,  Surgeon  to  the  New  York  Eye  and  Ear  Infirmary,  etc.  Illus- 
trated by  two  chromq-lithographs  and  numerous  wood  engravings. 

iE^"  This  treatise  is  written  with  a  special  view  to  the  needs  of  the  general  practitioner,  and  treat* 
the  subject  in  a  very  plain,  practical  way. 


Catalogue  of  the  Titles  of  the  Works  published  in 

WOOD'S  Library  of  Standard  Medical  Autbors. 


•0 

Second  Series.    Price,  ^1§.00.    Tolnmes  not  sold  separately.      9 


a 


VENEREAL  DISEASES.    By  E.  L.  KETES,  A.M..  M.D.,  Adjunct  Professor  of  Surgery,  and  Professor  * 

of  Dermatoloijy  ill  Bellevue  Hospital  Medical  College;  Consulting  Surgeon  to  the  Charity  Hospital :  M 

Surgeon  to  Bellevue  Hospital,  etc.  0 

^^  It  makes  a  handsome  volume  of  .361  pages,  thoroughly  covering  the  subject.     It  Is  written  with  fl 

special  reference  to  the  needs  of  the  physician  in  active  practice,  and  is  well  illustrated.  "S 

A  HANDBOOK  OF  PHYSICAL  DIAGNOSIS :  Comprising  the  Throat,  Thorax,  and  Abdomen.     By  g 

Dk.  PAUL  CtXjTIM.A'S,  Privni-Docent  in  Medicine,  University  of  Berlin.     Translated  from  the  Third  v 

German  Edition  by  ALEX.  XAPIER,  M.D.,  Fel.  Fac.  Physicians  and  Surgeons,  Ola^goio.     American  ^ 

Edition,  with  a  colored  plate  and  numerous  illustrations.  • 

Zd^~  This  standard  work,  the  highest  authority  upon  the  subject,  has  passed  through  several  editions  « 

in  Germany,  and  has  been  translated  into  French,  Italian,  Russian,  Spanish,  Polish,  and  English.     A  * 

volume  of  344  pages.  fe 

A  TREATISE  ON  FOREIGN  BODIES  IN  SURGICAL  PRACTICE.     By  ALFRED  POIJLET,  M.D.,  ^ 

Adjutant  Surgeon- Major,  Inspector  of  the  School  for  Military  Medicine  at  Val-de-Grace.    Illustrated  _ 

by  original  wood  engravings.     Translated  from  the  French.     Volume  I.  2 

^p°°  This  new  and  practical  work  upon  an  entirely  new  subject  is  of  unusual  interest  and  value.     It  ** 

is  translated  by  permission  of  the  author,  who  has  revised  and  corrected  it,  with  additions,  especially  J? 

for  this  series.     This  volume  is  illustrated  by  many  fine  engravings.  2 

A  TREATISE  ON  FOREIGN  BODIES  IN  SURGICAL  PRACTICE.     By  ALFRED  POULET,  M.D..  s 

Adjutant  Surgeon-Major,  Inspector  of  the  School  for  Military  Mtdicine  at  Val-dt-Grace.     Illustrated  m 

by  original  wood  engravings.     Volume  II.  « 

A    TREATISE    ON    COMMON    FORMS   OF   FUNCTIONAL    NERVOUS    DISEASES.     By  L.  S^ 
rUTZEL,  il.D.,  Visiting  Physician  for  Xervous  Diseases,  RayidalVs  Island  Hospital;  Physician  to      »•* 

the  Class  for  Xervous  Diseases,  Bellevue  Hospital  Out-Door  Department ;  and  Pathologist  to  the  Lu-  'f^ 

nalic  Asylum,  B.  I.  >>^ 

^fW"  This  volume  is  especially  prepared  for  use  of  general  practitioners,  and  treats  in  a  practical  way  *  s 

of  the  forms  of  nervous  disorders  commonly  met  with  in  practice.     It  makes  a  book  of  262  pages.  **  • 

DISEASES    OF   THE    PHARYNX,  LARYNX  AND  TRACHEA.      By  MORRELL  MACKEKZIE,  Sj 
M.D.,  Loudon.     Illustrated  by  112  fine  wood  engravings. 

P^~  This  work,  by  the  best  English  authority  is  just  completed,  and  will  be  welcomed  by  the  profes-  ^^ 

sion  in  America.     It  makes  a  large  volume  of  440  pages.  S  " 

THE    SURGERY.    SURGICAL    PATHOLOGY    AND    SURGICAL   ANATOMY  OF   THE    FE-  m9 

MALE  PELVIO  ORGANS  in  a  series  of  plates  taken  from  nature  with  commentaries,  notes,  and  X-  a 

cases  by  HEXRY  SAVAGE,  M.D.,  London,  Fellow  of  the  Royal  College  of  Surgeons  of  England,  one  €  2 

of  the  Consulting  Medical  Officers  of  the  Samaritan  Hospital  foi'  Women.    Third  edition,  revised  and  ftS 

greatly  extended.  ®  © 

p^"  32  full-page  lithographic  plates  and  22  wood  engravings,  with  special  illustrations  of  the  opera-  ^  A 

lions  on  Vesico- Vaginal  Fistula,  Ovariotomy,  and  Perineal  Operation.     This  is  the  cheapest  book  ever  _ 

published  on  any  branch  of  medicine  at  any  time,  and  is  almost  worth  the  entire  cost  of  the  twelve  « 

volumes.  jj 

THERAPEUTICS.     Illustrated   by   D.    F.   LINCOLN,   M.D.,    from    the  Materia    Medica   and  Thera-  % 
peutics  of    A.  TOSSEAU,  M.D.,   Professor  of  Therapeutics  of  the  Faculty   of  Medicine    of  Paris, 

fhysician   to   THotel   Dieu,  etc.,  etc.,  H.  PIDOUX.   M.D.,   Member  of  ihe  Academy  of  Medicine,  w 

Paris,  etc..  etc.,  and  CONSTANTINE  PAUL,  M.D.,  Adjunct  Professor  of  the  Faculty  of  Paris,  Phy-  A 

sician  to  the  St.  Antoine  Hospital,  etc.     Ninth  French  Edition,  Revised  and  Edited.     Volume  I.     Any  ** 

work  by  Trosseau  needs  no  introduction  to  the  Medical  Profes.eion — his  profound  knowledge,  his  admir-  "g 
able  facility  of  imparting  instruction,  and  his  delightful  style  commend  whatever  bears  his  name  to 

their  best  consideration.     This  work  is  said  to  be  superior  to  any  other  upon  the  subject,  and  one  which  * 

will  long  continue   to  be  a  standard.     The  editon  from  which  this  translation  is  made  has  been  ♦* 

thoroughly  revised  and  edited  by  Dr.  Paul,  and  brought  down  to  the  present  year.  j5 

THERAPEUTICS.     Translated  by  D.  F.  LINCOLN,  M.D.,  from  the  Materia  Medica  and  Therapeutics  * 

of  A.  TROSSEaU,  M.  D.,  Professor  of  Therapeutics  of  the  Faculty  of  Medicine  of  Paris,  Physician  to  « 

r Hotel  Dieu,  etc.,  etc..  H.  PIDOUX,  M.D.,  jfember  of  the  Academy  of  Medicine.  Paris,  etc.  etc.,  and  ft 

CONSTANTINE  PAUL,  M.D.,  Adjunct  Professor  of  the  Faculty  of  Paris,  Physician  to  the  St.  Antoine  ^ 

Hospital,  etc.    Ninth  Edition,  Revised  and  Edited.     Volume  II.  9 

THERAPEUTICS.     Translated  by  D.  F.  LINCOLN,  M.D.,  from  the  Materia  Medica  and  Therapeutics  of  * 

A.  TROSSEAU.  M.  D.,  Professor  of  Therapeutics  of  the  Faculty  of  Medicine  of  Paris,  Physician  to  * 

VHotel  Dieu,  etc..  etc..  H.  PIDOUX,  M.D.,  Member  of  the  Academy  af  Medicine.  Paris,  etc..  etc.,  and  ■ 

CONSTANTINE  PAUL,  M.D..  Adjunct  Professor  of  the  Faculty  of  Paris,  Physician  to  the  St.  Antoiyie  ^ 

Hospital,  etc.     Ninth  French  Edition,  Revised  and  Edited.     Volume  III.  jj 

DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE  EAR.— By  ALBERT  H.  BUCK,  M.D.,  H 

Instructor  in   Otology  in  the  College  of  Physicians  and  Surgeons,  New  Ttork;  Aural  Surgeon  to  the  I 

If.    Y.    Eye  and  Ear  Infirmary;  Editor  of  Ziem-^sen's  Cyclopedia  of  the  Practice  of  Medicine,  and  % 
Editor  of  '"4  Treatise  on  Hygiene  and  Public  Health.^'' 

MINOR  SURGICAL  &YNECOLOGY.  By  PAUL  F.  MUNDE,  M.D.  A  Manual  of  Uterine  Diagnosis 
and  the  Lessor  Technicalities  of  Gynecological  Practice,  for  the  Use  of  the  Advanced  Student  and 
General  Practitioner.     In  one  octavo  volume  of  392  Pages.     With  300  Illustrations. 

^^ff~  This  book  is  intended  to  contain  many  hints  concerning  the  minor  details  of  practice  in  the 
treatment  of  women,  commonly  overlooked  in  general  treatises.    It  is  written  especially  for  this  library. 


£2 


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Catalogue  of  the  Titles  of  Works  published  iu 

WOOD'S  Library  of  Standard  Medical  Authors. 

First  Serie§.    Price,  $1§.00.   Volumes  not  sold  separately. 


•J  REST  AND  PAIN.     A  Course  of  Lectures  on  the  Influence  of  Mechanical  and  Physiological  Rest  in 

a  the  Treatment  of  AccidRnts  and  Surgical   Diseases  and  the  Diagnostic  Value  of  Pain.     By  JOHN 

4.  HILTON,  F.R.S.,  F.R.C.S.     Edited  by  W.  H.  A.  JACOBSON,  P.R.C.S. 

«  DISEASES  OF  THE   INTESTINES  AND  PERITONEUM.     Comprising  Articles  on— Enteralgia, 

«  by   JOHN   RICH.'i.RD   WARDELL,  M.D. ;    Enteritis,  Obi?truction   of  the  Bowels,  Ulceration   of  the 

•^  Bowels,  Cancerous  and  other  Growths  of  the  Intestines,  Diseases  of  the  Caecum  and  Appendix  Vermi- 

J  formis,    by   JOHN   SYER  BRI3T0WE,   M.D.  ;   Colic,   Colitis  and   Dysentery,   by   J.  WARBURTON 

*■  BEGBIE,  M.D. ;   Diseases  of  the  Rectum  and  Anus,  by  THOMAS  BLIZZARD  CURLING,  F.R.S. ; 

m  Intestinal  Worms,  by  W.  H.  RANSOM,  M.D.  ;  Peritonitis,  by  JOHN  RICHARD  WARDELL,  M.D.  ; 

**  Tubercle  of  the  Peritoneum,  Carcinoma  of  the  Peritoneum,  Affections  of  the  Abdominal  Lymphatic 

»  Glands  and  Ascites,  by  JOHN  SYER  BRISTOWE,  M.D. 

.«* 

S  A    CLINICAL    TREATISE     ON     DISEASES    OF    THE    LIVER.       By    DR.    FRIED.    THEOD. 

•S  FRERICHS.     Translated  by  CHARLES  MURCHISON.  M.D.     In  Three  Volumes,  Octavo.     Volume  I. 

gg   •  Illustrated  by  a  full-page  Colored  Plate  and  numerous  fine  Wood  Engravings. 

^2  A    CLINICAL    TREATISE     ON    DISEASES    OF    THE    LIVER.       By    DR.    FRIED.    THEOD. 

*&  FRERICHS.    Translated  by  CHARLES  MURCHISON,  M.D.    In  Three  Volumes  Octavo.     Volume  II. 

0  g  Illustrated  by  a  fullpa'^e  Plate  and  numerous  fine  Wood  Engravings. 

t» 

«  ©  A   CLINICAL  TREATISE   ON   DISEASES   OF   THE  LIVER.     By  DR.  FRIED.  THEOD.  FRER 

•O^  ICHS.     Translated    by   CH.iRLE3   MURCHISON,    M.D.     In  three   volumes,  octavo.      Volume  III. 

^  S  llUistrated  by  a  full-page  Plate  and  numerous  fine  Wood  Engravings. 
^  88 

«*  MATERIA    MEDICA    AND    THERAPEUTICS.      (Vegetable    Kingdom.)     By    CHARLES^  D.   F. 

J  «.  PHILLIPS,  M.D. ,  F.R.C.S.E.,   Lectwer  on  Materia  Medica  at  Westminster  Hospital,  London.     Re- 

C8  2  vised  and  adapted  to  the  U.  S.  Pharmacopoeia  by  HENRY  G.  PIFFARD,  A.M.,  M.D.,  Pro/essor  of  Der- 
iiuitology.  University  of  tlie  City  of  Xew  York,  Surgeon  to  the  Charity  Hospital,  etc.,  etc.  This  prac- 
tical book  forms  a  volume  in  this  series  of  327  pages. 


«         A  CLINICAL  TREATISE  ON  THE  DISEASES  OF  THE  NERVOUS  SYSTEM.     By  M.  ROSEN- 
•■  THAL.   Profesior  of  Diseases  of  the  Nervous  System  at  Vie)ina.     With  a  preface  by  Professob 

9  CHARCOT.     Translated  from  the  Author's  revised  and  enlarged  edition  by  L.  PUTZEL,  M.D.,  Phys- 

iciin  to  the  Class  fm'  Nervous  Diseases,   Bellevue   Outdoor  Dept.,  and  Pathologist  to  the  Lunatic 
2  Asylum,  BlackwelVs  Island.     In  two  volumes.     Volume  I.     Illustrated  with  fine  Woodcuts.     This  new 

»*  edition  of  Prof.  Rosenthal's  work  is  pronounced  by  the  most  eminent  neurologists  to  be  the  best  treatise 

"r  extant  upon  the  subject,  clear  in  its  pathology  and  fuU  and  practical  in  therapeutics.     This  is  a  volume 

^  of  284  pages. 

« 

^  A  CLINICAL  TREATISE  ON  THE  DISEASES  OF  THE  NERVOUS  SYSTEM.  By  M.  ROSEN 
THAL,  Professor  of  Diseases  of  the  Nervous  System  at  Vienna.  With  a  Preface  by  Prof.  CHARCOl 
Translated  from  the  Author's  revised  and  enlarged  edition  by  L.  PUTZEL,  M.D.     Volume  II. 

Si 

>.        DISEASES    OF    WOMEN.      By    LAWSON    TAIT,    F.R.C.S.      A    new     Edition,    with    considerable 
©  additions,  prepared  by  the  Author  expressly  for  this  Library.     This  very  compact,  useful  book  makes  a 

I,  volume  of  204  pages,  with  illustrations. 

« 

■  INFANT    FEEDING,    AND    ITS    INFLUENCE    ON    LIFE  ;  Or,  The  Causes  and   Prevention  of 

«  Infant  Mortality.     By  C.  H.  F.  ROUTH,  M.D.     Third  Edition.     This  unique  work  forms  a  volume  of 

E^  2S6  pages  in  this  Library. 

L        A    PRACTICAL   MANUAL   OF   THE    DISEASES  OF  CHILDREN,  WITH  A  FORMULARY. 

ffl  By  EDWARD  ELLIS,  M.  D.     Thi7-d  Edition.    This  standard  book  makes  a  volume  in  this  series  of 

225  pages.  , 

A  MANUAL  OF  SURGERY.  By  W.  FAIRLIE  CLARKE,  M.A.  and  M.B.  (Oxon.),  F.R.C.8.,  Assistant 
Surgeon  to  Charing  Cross  Hospital.  A  new  Edition,  thoroughly  revised,  w>th  important  additions  by 
an  American  .~urgeon.     Nearly  200  illustrations.     Over  300  pages. 


f^Mv 


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